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in this issue PREVENTING AND ADDRESSING TEEN SUBSTANCE USE MEET YOUR NEW PRESIDENT, LISA WARD, MD, MSCPH, MS, FAAFP IT’S TIME TO BAN ASSAULT WEAPONS – PAST TIME


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Officers and Board

Staff

President Michelle Quiogue, MD

Susan Hogeland, CAE

Immediate Past President Lee Ralph, MD President-elect Lisa Ward, MD, MPH Speaker Walter Mills, MD Vice-Speaker David Bazzo, MD Secretary/Treasurer Shannon Connolly, MD Executive Vice President Susan Hogeland, CAE Foundation President Anthony Chong, MD

Executive Vice President shogeland@familydocs.org

Conrad Amenta Director, Health Policy camenta@familydocs.org Morgan Cleveland Manager, FP-PAC and Membership mcleveland@familydocs.org Jerri Davis, CHCP Director, CME/CPD jdavis@familydocs.org Brian Devine

Manager, Finance bdevine@familydocs.org

Adam Francis Director, Government Affairs afrancis@familydocs.org

AAFP Delegates Jeff Luther, MD Carla Kakutani, MD

Shannon Goecke

AAFP Alternates Carol Havens, MD Jay W. Lee, MD, MPH

Pamela Mann, MPH

CMA Delegation Ashby Wolfe, MD, MPA, MPH (Chair) Mark Dressner, MD Sumana Reddy, MD Kevin Rossi, MD Lauren Simon, MD, MPH Felix Nunez, MD, MPH

Elizabeth Lukrich

Director, Membership and Marketing sgoecke@familydocs.org Program Manager pmann@familydocs.org

Manager, Communications and Social Media elukrich@familydocs.org

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Shelly Rodrigues, CAE, FACEHP Deputy Executive Vice President srodrigues@familydocs.org

Nathan Hitzeman, MD, Editor Shelly Rodrigues, CAE, Managing Editor The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.

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California

Spring 2018

FAMILY PHYSICIAN st rong

m e d i ci n e

f o r

Cal i f or nia

features 14 Family Physicians Play a Major Role in Preventing and Treating Addiction

Diana Coffa, MD

16 The Medical Board of California is Reviewing Physician Prescribing History

Conrad Amenta

18 2018 All Member Advocacy Meeting and Lobby Day Break

Adam Francis

Records for Attendance, Contributions and Fierceness!

21 Research-driven Solutions Can Help Prevent and Address Teen Substanct Use

Geetha Subramaniam, MD

23 Meet Your New President, Lisa Ward, MD, MScPH, MS, FAAFP 26 Family Physicians Can, and Should, Manage Substance Use During Pregnancy

Tipu V. Khan, MD, FAAFP

28 Family Physicians Need to Know the 21st Century Smoker

Matthew Varallo

departments 6 Editorial

Taking an Opioid Pause

8 President’s Message

Does Your Tuesday Morning Look Like Mine?

10 Political Pulse

Shining a Bright Light on Primary Care Spending

12 Membership News

Connect, Share and Engage with Your Academy

30 EVP Forum

It’s Time to Ban Assault Weapons – Past Time

Nathan Hitzeman, MD Michelle Quiogue, MD, FAAFP Carla Kakutani, MD Shannon Goecke Susan Hogeland, CAE

For upcoming CME activities visit familydocs.org/cme California Family Family Physician Physician Spring Spring 2018 2018 California

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editorial

Nathan Hitzeman, MD

Taking an Opioid Pause Paradigm shifts in medicine do not happen overnight. Think diverticulosis and sunflower seeds.

works well, but few of my patients seem to accept that they have an opioid use disorder in the first place.

When the Academy announced this issue on addiction medicine, I had mixed feelings. Part of me is sick of talking about the opioid crisis and the multifactorial drivers behind it – direct-to-consumer (DTC) marketing and patient expectations, a zero pain tolerance culture, perioperative opioids that we inherit, war on pain, the obesity epidemic, a somatization nation and the whole Big Pharma OxyContin marketing fiasco. But the other part of me knows I need to accept that primary care is irrevocably intertwined with the opioid crisis and that we need to be part of the solution.

The toll in lives from addiction is all around us. At a recent visit, a physician patient of mine who specializes in addiction medicine lamented how he lost a brother to alcohol and drugs. A resident in our program gave a didactic presentation on outcomes of perioperative opioid prescribing patterns because a friend of hers from high school died from opioid overdose following a surgery after which things didn’t get better. A scientist-turned-lawyer friend of my father’s recently visited and mentioned that he lost a stepson to opioids. “Do you think it’s all these doctors prescribing the stuff who are the problem?” he asked me.

The toll in lives from addiction is all around us.

Our clinic adopted the Centers for Disease Control (CDC) guidelines and the 90 morphine equivalents opioid ceiling earlier this year. The reaction from patients was interesting. Some said, “I wondered when you guys were going to do that,” to “How am I going to go down on my meds and be able to function?” It’s an onerous process of reassurance, slow tapering, showering clonidine as a withdrawal panacea and motivational interviewing (“You can do this! You control your destiny, not this pill!”). It hasn’t been easy. I know some patients will not be able to taper to goal. Some will leave our practice and find their desired dose elsewhere. Some of us have buprenorphine training. It

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Shared decision making has been promoted since I was in medical school in the 1990s. It just sounds good – you and the patient deciding together what is right. But two decades later, I realize that there is still a place for paternalistic medicine and limits that need to be set. I have been taken to the wood shed too many times by inappropriate opioid and disability requests. The time has come to have a more rational approach.

The analogy with gun violence is inescapable. Of course, where there are more guns, there is more room for harm. The same with opioids. Who knows where some of our prescriptions go? We cannot verify that our patients lock their meds in the safe. How many of you have a safe? Who really has a safe? And patients need only take a dose before their scheduled visits to show that they themselves are taking the drug. But, I feel, similar to gun violence, a change is in the air. Before considering sending off an initial opioid prescription for anyone, even if for all the right reasons, I ask myself, “Am I possibly altering this person’s whole future with this prescription?” It’s like a surgical pause. Will this be a meaningful pause? Or are we doomed to become an opioid-caffeine-alcohol-smartphone-Netflix-sugar-fat-saltladen society? I wish I could bend space and time and say that there is no spoon, no narco, or whatever. Nevertheless, I am one man trying to make a change. And that has to count for something.


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p r e s i d e n t ’s m e s s a g e

Michelle Quiogue, MD, FAAFP

Does Your Tuesday Morning Look Like Mine? It is a Tuesday morning. I drive my daughter to junior high on my way to work; we gasp at the clarity of the surrounding mountains outlined by the pale peach sunrise after a dark and rainy night. I wave goodbye and turn up NPR on the radio; she walks the neatly xeriscaped path to meet friends, wearing her quiet smile. Because school starts at 7:30 am, I am usually one of the first people to arrive at work. I always feel like Mr. Rogers as I go through my ritual of trading my jacket for my white coat, turning on my desktop fountain and diffuser and then finally logging in to my computer. I review the schedule for the day looking for themes and patterns. Sometimes, three or four people will have the same initials. Usually, one complaint describes the majority of appointments: ear pain, cough, rash. Today, the winner is “personal,” which could be any diagnosis but really is only ever vulnerability, shame and courage. Dr. Brené Brown, a researcher and a storyteller at the University of Houston Graduate College of Social Work, has become well-known in recent years for her research on vulnerability, courage, worthiness and shame. I highly recommend reading and rereading Rising Strong and the most recently published Braving the Wilderness, just two of her many books. She has also given two TED talks which have gone viral, Listening to Shame and The Power of Vulnerability. Her ground-breaking research uncovered a commonality among behaviors meant to numb unwanted emotions and to avoid struggle. When we cope with adversity by trading authenticity for safety, the resulting shame spiral can itself result in anxiety, depression, eating disorders, addiction, rage, blame, resentment and pathological grief. In contrast, when we share our shame stories with someone who understands and responds with empathy, then shame cannot survive. When patients come to us and share their stories of shame, we must strive to meet them with empathy equal to the courage it took for them to admit their vulnerability. We must also encourage their inherent capacity to change. It should be fairly easy to understand how we might feel when roles are reversed. When you discover your precious child is using drugs or alcohol, shame and guilt can delay getting help for your family. When you are struggling with addiction yourself, getting help as a

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physician can even seem impossible. This is when Dr. Brown’s counterintuitive advice can save lives and heal families: “As a shame researcher, I know that the very best thing to do in the midst of a shame attack is totally counterintuitive: Practice courage and reach out!” “Owning our story can be hard but not nearly as difficult as spending our lives running from it. Embracing our vulnerabilities is risky but not nearly as dangerous as giving up on love and belonging and joy – the experiences that make us the most vulnerable. Only when we are brave enough to explore the darkness will we discover the infinite power of our light.” Asking for help is one of the most heroic actions you can take. You and your family are important and worth the perceived risk of reaching out. Did you know that the California Medical Association (CMA) Physicians’ and Dentists’ Confidential Assistance Line provides completely confidential doctor-todoctor assistance? This 24-hour phone service is for physicians, dentists and their family members who request help with problems of alcoholism, drug dependence or mental illness within their families. This service is free, and it will not result in any form of disciplinary action or referral to any disciplinary body. If you or someone you know might need help, please consider calling. (650) 756-7787 (Northern California) (213) 383-2691 (Southern California) Nowhere in this country has been spared the devastating effects of addiction. Countless variations of the disease that the DSM-5 labels as substance use disorder because there are countless stories of loss and isolation, redemption and hope, abound. These are the stories that fill up our daily routine. These are the stories we are not free to tell others, yet comprise our treasure of compassion. The recent media attention to an epidemic seems almost inappropriate to those of us who have witnessed throughout our career how addiction has relentlessly consumed families for generations, outside of the spotlight. At the end of the day, this epidemic just feels like a Tuesday.


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political pulse

Carla Kakutani, MD Chair, CAFP Legislative Affairs Committee

Shining a Bright Light on Primary Care Spending It is no secret to those of us who work in family medicine, and primary care in general, that our country’s health care system spends too much money trying to rescue patients from sickness instead of preventing illness and managing chronic conditions in a comprehensive and coordinated fashion. While payment rates for primary care clinicians has increased over the last five years, subspecialist payment and episodic care still far outpace that of primary care. This MUST change if California hopes to bend the cost curve and ensure it is paying for value instead of volume. Thanks to CAFP and your advocacy efforts, legislators are well aware that a compelling body of evidence clearly demonstrates investment in primary care delivers greater value to patients and health systems, resulting in fewer hospitalizations and emergency department visits, higher patient satisfaction and lower mortality. But despite this evidence, primary care remains undervalued. A Commonwealth Fund analysis identified underinvestment in primary care as one of four fundamental reasons the U.S. health system ranks last among high-income countries. Both public and private payers may claim to invest in primary and preventive care, but we have no way to verify that claim. California needs to change this. That is why CAFP is sponsoring legislation, AB 2895 (Arambula and Bonta), which will require health plans/ insurers to report total primary care medical expenditures (claims-based and non-claimsbased), including: • The percentage of medical expenses allocated to primary care compared to overall medical expenditures. • The methods plans/insurers use to support primary care. The bill is modeled after successful Oregon legislation, SB 231, which has helped consumers and legislators truly know which health plans/insurers prioritize primary care. The bright light has even led the lower primary care spending health plans to significantly increase their investment in primary care. 10

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The bill also will create a Primary Care Payment Reform Collaborative, composed of a wide range of health care stakeholders and experts, to help provide health plans/insurers and others with proven strategies to support primary care. The Collaborative will help align payment and infrastructure investments and offer guidance to HHS on how to improve the annual collection and reporting of primary care expenditure data. While only time will tell how effective our efforts are, your enthusiasm and participation in our advocacy efforts will be the key to CAFP’s success. If you would like to get more involved in CAFP’s advocacy work, and supporting this bill, I strongly encourage you to become a Key Contact and join our Grassroots Advocacy Team (https://www. familydocs.org/advocacy/key-contact).


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membership news

Shannon Goecke Director, Membership and Member Services

Connect, Share and Engage with Your Academy You’re never going to kill storytelling because it’s built into the human plan. We come with it. – Margaret Atwood, poet, novelist, literary critic, essayist and environmental activist Have You Shared Your Family Medicine Story Yet? Our year-long celebration, 70 Years, 10,000 Stories, highlights CAFP members’ stories about family medicine. We have already received dozens of stories and will be collecting more throughout the year. I love all the stories we’ve received, but here are a few of my favorite excerpts: The children cried, and I cried with them; partly for their pain, but also for the love that the children shared together. (Brent Sugimoto) I have been privileged to attend Pakistani weddings and Vietnamese naming ceremonies, I have received red eggs from Mien patients for New Year and chicken curry with handmade chapatis kept warm in kitchen towels for a surprise lunch. Scattered across these decades, there are little girls in every color of the human rainbow who carry my first name. (Kim Duir) I have a sense we live in a benign universe that cares for us, and as physicians we are part of that process, a vital link to do good things for others and our planet. (Jon Malachowski) Stories can be in the form of written narratives, audio or video recordings, photographs, illustrations, poems – anything that fires your imagination! Send your story to myfmstory@familydocs.org and add your voice to our narrative.

She chose the name, “The Nocturnists,” (referring to a hospital physician who works only at night) because of its sense of mystery. CAFP member Ali Block, San Francisco, serves as executive producer. Ali and her husband Tim are also executive producers on a documentary film called Dr. Feelgood, which explores the ethical dilemma of opiate prescriptions. The sold-out The Nocturnists show I attended, at San Francisco’s Brava Theatre, was built on the theme of love. The storytellers – physicians, residents and nurses from a variety of specialties and backgrounds – told tales of love and loss, comfort and grief, fear, courage and grace. In between stories, guitarist-composer Scott Gagner provided peaceful musical interludes. I’ll be at The Nocturnists’ next show in San Francisco in April, as they highlight the theme of Death and Dying. To find out about future events, subscribe to their podcast; for more information about becoming a The Nocturnists storyteller, please visit http:// thenocturnists.com. Join Our Community and SPARK a Conversation In late February, your Academy launched SPARK, our exclusive online platform where members can connect, share and engage. Hundreds of members are engaging in conversations on topics such as free and low-cost weight loss strategies for patients, using virtual patient visits to keep at-risk patients engaged in their care, ways to address sexual harassment in medicine and much more. We’ve started with an all-member community and an advocacy community that any member can join. We also have invitation-only special interest groups.

A Word about The Nocturnists Speaking of stories, I recently had the privilege of attending an event put on by a physician story tellers group called The Nocturnists. The Nocturnists brings likeminded health care workers together in an intimate, creative space to share experiences, build community, reduce burnout and remind one another why they do the work they do. Stories are told live, on stage.

If you’re not on SPARK, you’re really missing out! To join the conversation, simply go to spark.familydocs.org and click SIGN IN in the upper right corner. Click “Can’t Access Your Account” and enter your email address. Our system will immediately send you an email with a link to log in, create your password and join the conversation.

The group was created by Dr. Emily Silverman, an academic hospitalist at the Zuckerberg San Francisco General Hospital.

As always, please reach out to me directly, Shannon Goecke, sgoecke@familydocs.org, if you need help.

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addressing addiction

Diana Coffa, MD

Family Physicians Play a Major Role in Preventing and Treating Addiction In the face of the opioid crisis, it has become undeniable that all physicians have a role in preventing, identifying and treating addiction. As family physicians, we are uniquely positioned and skilled to do all three of those things. Fortunately for us and for our patients, addiction medicine is one of the few specialties that is actively seeking to partner with and empower primary care providers. This is in large part because they recognize the value of the whole-person and family-oriented approach we bring to treating addiction. Some physicians doubt whether managing substance use disorders (SUD) is within their scope of practice. They point out that SUDs develop because of social, psychological, cultural, political and economic factors and claim that this means SUD is not a disease, but a social/emotional problem. This claim reveals a misunderstanding of the nature of complex chronic disease. Diabetes, for example, is partly a disease of the pancreas and the glucose receptors. At the same time, it is a social disease, driven by social and cultural norms; it is a political disease, driven by food subsidies, school lunch policies and regulations; it is an economic disease, driven by poverty; it is a psychological disease, driven by stress and by personal choices; and it is a geographic disease, driven by food access and food culture local to specific neighborhoods and regions. The course of diabetes is dictated by decisions made by the patient, but those choices are largely compelled by circumstances. At the same time, diabetes has a strong genetic component and can only occur in the presence of measurable physical changes. Substance use disorder is also a complex chronic disease that is mediated by social factors. It is a social disease, often driven by trauma, isolation and childhood abuse, neglect or grief; it is an economic disease, driven by poverty; it is a political disease, driven by policies that have an impact on access to drugs and to treatment; it is a geographic disease, driven by local drug access and culture; and it is a psychological disease, driven by stress and by personal choices. At the same time, it has a strong genetic component and is characterized by measurable physical changes to the brain. Changes in dopamine receptor populations, reduced function of executive control pathways and increased activation of reward pathways in the brain lead to the symptoms of craving and compulsion that characterize the disease. Like diabetes, SUD is both psychological and physical. It is both a disease of the individual and a disease of society. This complexity is exactly what we specialize in as family physicians. We can apply the same tools we use for other chronic diseases to manage addiction, and we are well equipped to do so. 14

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Prevention Family physicians are familiar at this point with the importance of cautious and closely monitored opioid prescribing to prevent iatrogenic addiction, diversion and death. Many physicians are less familiar with strategies for preventing substance use disorders more broadly. Ninety percent of people with SUD began using alcohol or drugs before the age of 18. Before drug and alcohol use begins, high risk children can be identified and measures taken to protect them from early onset use. Children who experience adverse childhood events (ACEs) such as physical, emotional or sexual abuse and neglect, violence in the home; substance use or mental illness in the household; parental incarceration and parental separation or divorce are at increased risk of early onset drug and alcohol use. Youth with low parental supervision, exposure to peer substance use and high degrees of neighborhood residential instability are also at increased risk. Though low socioeconomic status (SES) is associated with early drug use, when low SES children have access to afterschool sports, clubs and other drug-free activities, their risk returns to nearly that of higher SES children. Family physicians can intervene at the level of the family, the individual patient and the community. At the family level, physicians can ensure that parental SUD and mental health issues are well treated and can encourage the family to discuss risks with the child and support her or him in finding alternative enjoyable activities. At the individual level, physicians can discuss drug use and risk with children and adolescents, helping them consider their interests and goals and encouraging them to pursue nondrug related activities. The presence of an adult mentor strongly protects children against developing SUD. Physicians, family members and teachers are all potential mentors, and physicians of at-risk youth can be extraordinarily positive influences. Because adolescent drug use can be a coping strategy for managing untreated mental health problems, identifying and treating adolescent depression, anxiety, PTSD, ADHD and other mental health problems can also prevent the development of SUD. At the community level programs that stabilize neighborhoods, such as rent control, community gardens and community empowerment can decrease adolescent drug use in affected neighborhoods, and advocating for and supporting after school programs can protect vulnerable youth. Family physicians who are engaged community members can reduce drug use in their communities by advocating for these measures.


Identification In the adolescent and adult population, validated single question screening tools can identify patients who are engaged in risky drinking or drug use. A brief intervention that includes compassionate, patient-centered discussion of risks can help return patients to safe levels of use and prevent addiction from developing. Because of the proven effectiveness of screening and brief intervention, the United States Preventive Services Task Force USPSTF recommends that all adults be screened annually for risky alcohol use. The American Academy of Pediatrics (AAP) recommends that all children be screened annually for alcohol and drug use. These same screening tools, followed by a brief assessment, can also identify people who have already developed a SUD. While more than 20 million people in the US are estimated to have a substance use disorder, approximately two million receive treatment. This gap in treatment access is in part because the disease is often not identified until very late in its course. By screening every patient, primary care providers can contribute to closing the treatment gap. Treatment The role of family physicians in substance use treatment has changed dramatically in the last 20 years. While referral to specialty care used to be the preferred treatment strategy for family physicians, effective medications for both opioid use disorder and alcohol use disorder have made it possible for family physicians to be the primary treatment provider for many people with SUD. Studies suggest that buprenorphine provision in primary care is at least as effective as buprenorphine provision in specialty care. This is not surprising when we consider the social complexity of substance use disorders. A family physician who knows the patient’s family and social context and who has a longitudinal understanding of the patient’s life can be extremely effective in providing counseling and support around behavior change. In addition, integrating buprenorphine treatment into primary care allows the treatment relationship to be stabilized by other points of contact. A patient who is being treated for opioid use disorder but is also bringing in his child for well child visits and being managed for hypertension may be more likely to stay in care because of the multiple points of contact. The scaffolding of a long- term, multidimensional relationship is a powerful

contributor to treatment success that is unique to family physicians. As with diabetes, some cases of SUD can be managed effectively in primary care and some will require additional support from specialist referral. Referral to psychotherapy or to specialty drug treatment programs will be appropriate in complex cases, especially those accompanied by severe psychiatric or social pathology. As family physicians take a leadership role in addressing addiction, it will become critical for us to develop effective partnerships with substance use disorder treatment specialists in our communities. While treating substance use disorder can be intimidating and seem overwhelming at the start, family physicians are well equipped to manage this complex chronic disease. Effective medications have brought the disease solidly into our scope, and as we become more familiar with using them, we will begin to experience the extraordinary satisfaction of providing treatment that not only saves lives but also rebuilds families, careers, and communities. Diana Coffa, MD, is the Director of the UCSF/SFGH Family and Community Medicine Residency Program.

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Conrad Amenta D i r e c t o r, H e a l t h P o l i c y

The Medical Board of California Is Reviewing Physician Prescribing History Here’s What You Need to Know The Medical Board of California (MBC) has entered into an interagency agreement with the California Department of Public Health (CDPH) to review death certificate information for cases in which a medical examiner has determined the cause of a patient’s death to be overdose involving at least 80 morphine-equivalent units. The MBC is cross-checking that information with the California Department of Justice’s Controlled Substance Utilization Review and Evaluation System (CURES) to identify the physicians who prescribed medication to patients deemed to have died from overdose. CAFP is working closely with the California Medical Association (CMA) and others to understand the scope and motivation of the MBC’s review. The situation is fluid, however, and the following represents our understanding at this moment: The MBC initially reviewed cases from 2012-2013 and did not take physicians’ prescribing history into account when deciding if and when to initiate a review of prescribing practices. It intends to review 2014-2015 and 2016-2017 data as it becomes available from CDPH. MBC appears to be sending a template letter it uses in cases in which a third-party, such as a patient, has filed a complaint when corresponding with physicians identified by this review. It appears, however, that MBC is responsible for initiating the review, not any third party. What should CAFP members do if they receive a letter from the MBC? First and foremost, it’s important that to understand your right to legal representation, and that before disciplinary action can be taken, you also have the right to an extensive administrative procedure involving witnesses and the ability to appeal. CAFP strongly advises you to retain and consult an attorney or reach out to your organization’s risk management department immediately upon contact from the MBC. Very short deadlines can be triggered upon receiving documents from the MBC; it is recommended that at no point during an investigation should you be without legal counsel. If, prior to engaging a lawyer,

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you find yourself on the phone with a MBC investigator, it’s perfectly appropriate to politely end the conversation while indicating an intent to confer with legal counsel. CAFP maintains a list of attorneys who represent physicians on its website: http://www.familydocs.org/practice-resources/ finance-center/consultants The MBC enforcement process can be lengthy and expensive. The average time a MBC investigation remains open now exceeds one year. While your instinct might be to convince the investigator to close the matter quickly, it is important to take the time to confer with legal counsel, remember and document the relevant facts and then carefully communicate them to the investigator. This helps ensure an accurate investigatory record. Upon launching an investigation, MBC investigators typically request medical records. The investigator also may attempt to discuss the matter with the physician. The MBC investigator may be working directly with a prosecutor in the Attorney General’s office, who may attend an initial meeting. After reviewing evidence and conducting any interviews, the MBC may decide to escalate its investigation by bringing a disciplinary action, which can vary from public letters of reprimand, suspension or rescission of licensure or even referral to criminal authorities. Given the potentially grave consequences of even minor forms of discipline, CAFP urges members to fully avail themselves of their extensive procedural due process rights. A detailed explanation of the MBC investigation process is available at: http://www.mbc.ca.gov/Enforcement/ enforcement_process.pdf CAFP is carefully monitoring this situation and will provide updates as they are received. If you have any questions or information to share, please contact CAFP staff at 415-3458667 or cafp@familydocs.org.


Adam Francis D i r e c t o r, G o v e r n m e n t R e l a t i o n s

2018 All Member Advocacy Meeting and Lobby Day Break Records for Attendance, Contributions and Fierceness! In early March, nearly 200 family physicians, residents and medical students from across the state converged on the State Capitol for CAFP’s All Member Advocacy Meeting (AMAM) and Family Medicine Lobby Day. The attendees discussed important topics in health care and advocate for family medicine and patients. The AMAM is designed to give participants the tools to become the leaders of the future and effective advocates for themselves and their patients. With record breaking attendance at both the AMAM and Lobby Day, it was immediately clear that this year’s theme was going to be “No More Family Medicine Nice; it’s time for Family Medicine Fierce!” DAY ONE The conference kicked-off with a legislative briefing by Legislative Affairs Committee Chair Carla Kakutani, MD and CAFP Legislative Advocate Jodi Hicks describing last year’s successful efforts to increase Medi-Cal provider payment and secure $100 million in State General Fund revenue to support primary care residency training programs. An informative panel of local chapter leaders, Drs. Warren Brandle, Rosanne Chen, Anthony Chong and Mss. Sabrina Bazzo and Shannon Goecke, shared best practices on how members can be involved with CAFP close to home followed. State Senator Richard Pan, MD and the Co-Founder of political consulting group, The Arena, Kate Catherall shared what it is like to be a physician running for public office and presented tips on how to tell your story – it was a big hit. CAFP was very excited when Ms. Catherall asked whether any attendees were considering such a run and lots of hands went up! We look forward to hearing more from these inspired family physicians! Rounding out Day One was a panel of legislative staff members teaching attendees the best ways to maximize their visits with legislators and legislative staff. The panel featured: • Eduardo Martinez, Chief of Staff to Assemblymember Todd Gloria • Lisa Murawski, Consultant, Assembly Committee on Appropriations • Scott Ogus, Consultant, Senate Committee on Budget • Taylor Giroux, Legislative Director for Assemblymember Adam Gray 18

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DAY TWO The second day of the conference jumped into gear with the announcement of the 2018 Hero of Family Medicine Award. The Hero award is given annually to a CAFP member who has gone above and beyond the call of duty to advocate for patients, colleagues and the family medicine specialty. This year, the award went to Jay W. Lee, MD, MPH for his efforts to strengthen the family physician community through education, advocacy and leadership. Serving in various capacities with CAFP over the past decade, Dr. Lee has worked to address the primary care physician shortage, ensure access to care for all patients, increase the voice of family physicians in health policy and improve physician workforce diversity. Attendees then heard the truly inspiring personal stories of CAFP President-elect Lisa Ward, MD and Santa Rosa Family Medicine Residency Program Director, Tara Scott, MD about how, despite facing its own dire challenges, the family medicine community rose up from the ashes of the Sonoma County fires to ensure vulnerable patients maintained access to care.


The CAFP Board of Directors heard testimony on several resolutions they will consider action throughout the year, with a report back to the 2019 AMAM. The AMAM Delegates took action on one resolution: a game-changer to increase FP-PAC’s ability to be a much bigger force in electing family medicinefriendly candidates to state office. Resolution A-03-18 directs a $24 dues increase per eligible Active member to support FPPAC’s mission of electing true family physician champions to the State Senate and State Assembly. Individuals who do not want this portion of their dues to go to FP-PAC, or are unable to give to the PAC based on the organization that pays their dues (or if they are a foreign national without a green card), may choose instead to direct that amount to CAFP’s general fund. Even this small amount per member will make a tremendous difference in FP-PAC’s ability to support candidates such as Dr. Pan, who faces a primary and general election challenge in his re-election race this year. FP-PAC’s support will mean Dr. Pan can focus more campaign resources on such important activities as getting out the vote.

Day Two also featured a Keynote Address from California Insurance Commissioner Dave Jones, a special training on Achieving Health Equity and Diversity from AAFP’s Manager for the Center for Diversity and Health Equity Danielle Jones, MPH, and an interactive learning session on how to meeting with legislators and get involved in family medicine advocacy. FAMILY PHYSICIANS POLITICAL ACTION COMMITTEE AMAM attendees broke all previous fundraising records, contributing more to the Family Physicians Political Action Committee (FP-PAC) than at any other CAFP meeting ever! More than 150 contributors raised in excess of $33,000 for FP-PAC – the only political action committee in California that makes direct contributions to pro-family medicine, pro-patient state legislative candidates and select statewide offices. Although they are the most fiscally-challenged members, more than 40 students and residents in attendance showed what true advocacy is by stepping up and contributing to FP-PAC, part of

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a donation match offer spearheaded by FP-PAC Board Member Lee Ralph, MD. FPPAC Chair Jay W. Lee’s own match challenge was met when more than 10 non-AMAM attendees contributed over the weekend. FP-PAC thanked its donors Sunday evening during the sixth Annual FP-PAC Donor Reception, which featured special legislative guests. If you have not yet contributed to FP-PAC in 2018, please go to our donation page (https://familydocs.secure.force.com/pac/) to ensure that family physicians can continue our important electoral advocacy. FAMILY MEDICINE LOBBY DAY Family Medicine Lobby Day was once again a resounding success – 110 family medicine advocates met in more than half of all legislators’ offices to support AB 2895 (Arambula and Bonta), CAFP’s sponsored legislation to require health plans to report the proportion of spending they allocate to primary care. AB 2895 also establishes a Primary Care Payment Reform Collaborative to help align payment and infrastructure investments, as well as offers guidance on how to improve the annual collection and reporting of primary care expenditure data. This was by far the largest turnout for Family Medicine Lobby Day in CAFP’s 70-year history. It was an inspiring and exciting weekend! We invite any and all CAFP members interested in advancing family medicine and patient protections to join us at next year’s All Member Advocacy Meeting and Family Medicine Lobby Day, taking place March 9-11, 2019 at the Citizen Hotel in Sacramento.

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California Family Physician Spring 2018


Geetha Subramaniam, MD Deputy Director, Office of the CCTN Director, The National Institute on Drug Abuse

addressing addiction

Research-driven Solutions Can Help Prevent and Address Teen Substance Use Three quarters of adults in treatment for substance use disorder (SUD) began using in their teenage years. About 1.1 million adolescents needed treatment for a substance use (SU) problem in 2016, but only 16 percent received it. Thus, it’s critical to intervene early in teens showing signs of SU – to protect them from negative impacts on brain development and the potential for chronic and recurring SU through adulthood. Let’s look at what the research shows about the benefits of identifying and addressing substance use in your adolescent patients. Research Shows Family Physicians Can Make an Impact on Teen Patients Family physicians are in a unique position to identify SU in teens and intervene early when use is identified; family physicians can have a powerful impact on teens when they engage them in a discussion about their SU. While The National Institute on Drug Abuse (NIDA) does not develop guidelines or clinical recommendations, we do support science that informs these efforts. Here’s what we know from the research: • Prevention messaging can delay SU initiation in teens who receive these messages from health care providers. • Early interventions can improve outcomes with teens who are using substances, or who have an SUD. They can also prevent negative long-term health consequences, as they do for many other medical issues. Your brief advice can help teens quit. Brief advice and developing an action plan can help increase quit rates. Universal Screening: Supported by Research Based on research findings, American Academy of Pediatrics (AAP) supports screening all adolescent patients at all visits for SU, a practice known as universal screening. Benefits to universal screening, include: • It helps avoid missing key information. Using validated screening tools can help you collect more accurate information than relying on clinical impressions alone. Patients are also less likely to feel singled out and defensive and it helps ensure that at-risk patients get help sooner. • It doesn’t take more time when using electronic screening tools. Research has found that adolescents prefer selfscreening, and it may be more efficient and reduce time compared with clinician screening.

It facilitates the conversation about SU. Screening offers an opportunity to start SU conversations with your patients. Research suggests that most patients want physicians to raise sensitive topics and have more positive impressions of them when they do.

After You Screen So, what do you do next? During all visits, advise teens that NO SU is the best choice for their health. If use is detected, motivational interviewing can guide conversations that help patients compare the benefits of continued SU with those of reducing or stopping. Patient simulation courses on motivational interviewing can help enhance skills in this area. • For No Use: Praising your patient’s decision not to use; providing early prevention messages at regular intervals can help him or her refrain from use. • For Mild/Moderate Use: The AAP suggests administering the CRAFFT tool as a conversation starter about your patient’s plans to avoid future unhealthy situations and decisions. Next, recall your patient’s motivations for using, recommend quitting, offer brief advice about the health benefits of abstinence and explain the potential harms of SU on your patient’s body and developing brain. Offering this information can help increase quit rates. Personalizing advice to quit, particularly using a patient’s strengths and interests, like sports and family relationships, can also be effective. Establishing a change plan may help patients use less often or in smaller amounts if they are unwilling to quit. • For Severe Use: In addition to strategies mentioned above, a more comprehensive evaluation to determine an SUD diagnosis and impact on functioning is recommended. This evaluation

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Adolescent SU Screening Tools Two validated screening tools from NIDA can help you assess for SUD risk among adolescents 12-17 years old. Using screening tools such as these can help you obtain accurate information about your patients’ SU. California Family Physician Spring 2018

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will help determine if treatment interventions can be delivered on-site with behavioral specialists or if the patient should be referred to an SUD specialist for ongoing management, including management of co-occurring disorders.

For teens reporting any SU, ensure adequate follow-up is provided at your office. If Treatment Is Needed Treatment for SUD should address the patient’s needs holistically and should be provided by a physician trained in these techniques. You might consider one of three, evidence-based treatment approaches detailed in the Principles of Adolescent SUD Treatment: A ResearchBased Guide. These approaches include medications to treat opioid use disorder. Results from two controlled clinical trials show that buprenorphine is safe and effective in improving abstinence from opioids in adolescents. If a referral to treatment is needed, your clinical judgment can guide which treatment options you recommend. Want to Learn More? CAFP joined a coalition of providers to help develop a CME course about adolescent SU, with scientific consultation from NIDA. The course explains how to identify and address SU in adolescent patients – including conversation starters, following up with patients after use is identified and information about opioid and Rx medication misuse. For additional physician-focused information about addiction, visit NIDAMED – a web portal featuring clinical guidance, patient information, CME courses and more.

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California Family Physician Spring 2018


Meet Your New President

Lisa Ward, MD, MScPH, MS, FAAFP CAFP’s new President, Lisa Ward, MD, MScPH, MS was sworn into office by AAFP President-elect John Cullen, MD at the recent Family Medicine Clinical Forum in Monterey. The last issue of California Family Physician carried a number of articles about the catastrophic 2017 wildfires’ impact on Sonoma and other California counties, including one by Dr. Ward, whose day job is Chief Medical Officer for Santa Rosa Community Health (SRCH). Her article, “Santa Rosa Is Rising!” detailed the response of the physicians and other health care providers after the loss of SRCH’s largest health center. The Vista Campus served 24,000 of SRCH’s 50,000 patients and housed the 36-resident family medicine residency program continuity clinic. In this article, we catch up on the status of caring for those 24,000 patients and the emotional state of the heroic health care clinicians serving those patients and rebuilding, but we’ll also help you get to know Dr. Ward a little better. Some details: Dr. Ward graduated from the University of California, San Francisco School of Medicine in 2001 and completed her residency at UCSF Family and Community Medicine at San Francisco General Hospital in 2004. She holds a Master of Science and a Master of Science in Public Health and has served on the CAFP Board of Directors, the FP-PAC Board of Directors, the Legislative Affairs Committee and as Secretary-Treasurer before moving up to Vice Speaker, Speaker and President-elect.

If distant memory serves, you were an intern in former CAFP legislative advocate Tom Riley’s Sacramento office – what prompted that and how did it affect you? I was in college at UC Davis at the time. I was volunteering at a student-run community clinic that cared for many undocumented residents, mostly poor working families. It was 1994 and California was divided by several issues. I enrolled as an intern in Tom Riley’s office because I wanted to understand the issues better. Proposition 186 was a ballot initiative to establish a single-payer state-run health system. It went down to defeat, but it was a radical concept at the time. That same year, then Governor Pete Wilson strongly supported Proposition 187, which prohibited undocumented immigrants from using publiclyfunded social services including health care, education and other basic services. It passed but was later found unconstitutional in Federal court and never implemented. I was politically activated, if not ignited, by my experience in those times, and have been involved in policy since. You are Chief Medical Officer for Santa Rosa Community Health – in that capacity, how many physicians do you oversee and what is your greatest challenge beyond having to rebuild your biggest health center and care for all the patients in the interim? I oversee about 100 physicians. The biggest challenge is building the systems around the clinicians so they can do their best work and have the deepest impact. This includes eliminating unnecessary steps from EHR workflows, making the referrals system easier to use, onboarding people so they are up and running as quickly as possible in the systems around them or making high-quality care happen because it is the easiest path to take. As it turns out, health care is, well, complicated. And so, the systems in which health care transactions take place affect efficiency, joy in practice, connection to patients and colleagues’ quality. These are truly important aspects of our daily practice. So, I think about systems a great deal. Tell us about your family – Brian and Gus and Cora – and how do you achieve work-life balance. As I think of my family, it takes my breath away how much they mean to me. They are actually my reprieve from work. My partner Brian runs our house, remodels it slowly, manages the complex schedules of two busy kids and is an aspiring author. He keeps me going and keeps me upright. Gus is nearly seven-years-old and in first grade. He is learning to read in Spanish at his immersion school and his first sentence in Spanish was, “Mama—caca!” Insert giggles here. He is an extroverted, loving kid who craves

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connection and cuddling and tickling. He is really good at soccer and just started wrestling. He’s like sunshine. Cora just turned nine and is in third grade. She is introverted and a little bit shy. Yet, her Spanish is so beautiful that people comment on it constantly when she speaks in public. She devours books of all kinds. She is an amazing athlete and really enjoys soccer. And she is a consummate negotiator, money manager, lemonade-stand manager and Girl Scout Cookie seller. She is persistent, and I think that will likely drive me crazy in the short run but serve her well in the long run. I am going to be brutally honest here. I really resent the term worklife balance. Perhaps it is because I can never master it. Truthfully, I am not even sure how to be good at work-life balance. At the same time, I cannot stop striving for something better since the balance piece is always off kilter in a different way. I struggle constantly when making decisions to increase the time I can be at home with my kids and family and friends with my personal drive to work hard at work and do good work. I love to run but could be in better shape. I work out several times a week. I get a massage once a month. Mostly, I try to make the time count when I am home, so I don’t work or talk on the phone much when my kids are around. I don’t use my phone much and screen time is short so we can hang out together. 24

California Family Physician Spring 2018

How have you kept yourself sane in the midst of destruction and challenges posed by the fires – what keeps you centered? This experience has been unbelievably challenging and extraordinarily rewarding at the same time. Honestly, I mostly achieved keeping my composure. Sanity is altogether different. The internal level of turmoil, distress and doubt has been high. This process has yielded such a rapid pace of change and decision making with a healthy dose of uncertainty. To keep going, I have done what I can, a little of this and a little of that. When I couldn’t sleep because my mind was spinning from the pressure of worry, I meditated. I have tried really hard to get sleep, even when I didn’t exercise. And now that I am sleeping better I have added back regular exercise. The beacon in all of this that has kept me centered is the early, unwavering principle of our executive team to take care of our employees and our patients. Every subsequent decision has been taken with that purpose. Because the principle resonated so deeply with my calling I can take steps forward whether small or large. Can you give us an update on caring for 24,000 patients and rebuilding Vista Campus? How is everyone coping? How are YOU coping? The most significant loss for our organization was the tremendous damage to our Vista Campus. The building has required a complete rebuild of its inner construction. This clinic was the home of our


for advertising information, contact beloved Santa Rosa Family Medicine Residency Program and the medical home for 24,000 patients. For the first three months after the fire, we were in what we affectionately call “The Sardine Phase” where we crammed the majority of the 200 staff and 80 providers from Vista into our next largest site. We expanded hours and staff there so that it was working at about 150 percent of its normal capacity. We also transferred providers and staff in small groups to our other eight sites. Beginning in late December, we have been in a phase of “Expanded Spaces and Places.” In December, we added mobile clinic vans and “Clinics in a Can,” which are single clinic rooms in refitted shipping crates. We also quickly rented new spaces for administrative work so that any existing spaces within clinics, like offices, were turned into exam rooms so patients could be seen most easily. For example, the Residency Program administration, teaching space and conference rooms were moved across town just in time for the recruitment season. In January, we opened a clinic we call Fiesta Campus that operates out of two vans and six cans. The early expansion allowed us to add back 20 of the over 50 exam rooms lost. This March, two additional sites will open. One is leased medical space where the residency and many of the faculty will practice next year. The second is a newly-constructed clinic called Dutton Campus that we had planned to open in 2018; now it will open with more hours and more providers. The opening of these two clinics will add about 35 exam rooms for patient care, replacing nearly all the rooms that were lost in the fires. Finally, the “Rebuild Phase” lasts from March 2018 to 2019 while we rebuild the damaged Vista Campus. We expect it to open in early 2019. It will once again house the residency training program, our substance use treatment programs for adults and pregnant women, the HIV program, HCV program and the many other primary care services once provided at Vista Campus. It promises to be a beautiful, expansive clinic that will be better than ever!

MICHELLE GILBERT 501-221-9986, ext.120 mgilbert@pcipublishing.com

California Family Physician Spring 2018

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addressing addiction

Tipu V. Khan, MD, FAAFP

Family Physicians Can, and Should, Manage Substance Use During Pregnancy Substance use (SU) during pregnancy is unfortunately more common than most clinicians assume. It is estimated that the rate of alcohol use during pregnancy is 9.4 percent, cannabis 9-15 percent, opioids two percent, stimulants one to ten percent and tobacco 16 percent. One study found that antepartum maternal opioid use increased nearly five-fold from 2000-2009. Of note, polysubstance use is the norm rather than the exception in substance using pregnant women. We can identify these patients using a systematic methodology. Outcome data from the SBIRT model (Screening, Brief Intervention, and Referral to Treatment) shows a 40-55 percent reduction in harmful use of certain substances. I recommend using a SBIRT-style model like the one below.

Screening: Clinicians should use a validated screening tool at each trimester to screen for SU. The most commonly used tools include the 4Ps, NIDA Quick Screen and CRAFFT. More frequent screening is indicated if the patient has a family history of SU, frequent encounters with law enforcement agencies, SU by a partner, physical violence or nicotine use. Domestic violence, human trafficking and psychiatric comorbidities such as depression and anxiety tend to co-exist and should be screened for as well. Brief Intervention: Engaging the patient by using short conversation, feedback and advice is a billable procedure using the CPT codes listed below.

Payer

Code

Description

Fee Schedule

Commercial Insurance

CPT 99408

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$33.41

CPT 99409

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$65.51

G0396

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$29.42

G0397

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$57.69

H0049 H0050

Alcohol and/or drug screening

$24.00 $48.00

Medicare

Medicaid

Alcohol and/or drug screening, brief intervention, per 15 minutes

Reproduced from: https://www.samhsa.gov/sbirt/coding-reimbursement

Referral to Treatment: Multiple behavioral treatment options exist for managing SU and include cognitive behavioral therapy (CBT) via a therapist or psychologist, in-office motivational interviewing by the clinician or trained staff and referral to Narcotics or Alcoholics Anonymous to name a few.

should be avoided when possible. Sixty percent of women stop drinking alcohol when pregnancy is confirmed. If a patient is using alcohol or sedative-hypnotics, an inpatient medically-managed detoxification program is recommended, given the risk of withdrawal seizure.

Initiate nicotine medication assisted therapy (MAT) in office. Refer patients to an experienced clinician to manage opiate MAT including DATA 2000-waivered clinicians for buprenorphine and methadone clinics.

Cannabis: The rate of cannabis use is rising with the legalization in our state. Limited data suggest cannabis is not a teratogen. The data support the concept that cannabis exposure may increase the risk of developmental and hyperactivity disorders as well slow cognitive maturation, however. The risk of stillbirth is two-to-threefold higher in women who smoke cannabis products than those who do not. Interestingly, the use of cannabis during pregnancy increases the risk of cannabis use in the offspring in adulthood

Management: As family physicians we manage multiple substances. Alcohol and Sedative-Hypnotics: Alcohol is clearly teratogenic. Data regarding sedative-hypnotic teratogenicity is not clear and 26

California Family Physician Spring 2018


when controlled for other factors. Cessation is recommended and can be managed with CBT. Opioids: Medication-assisted treatment (MAT) with methadone or buprenorphine is the standard of care for the management of opiate dependence during pregnancy. Opioid withdrawal, albeit not life-threatening, can cause uterine contractions and lead to still birth or pre-term labor and thus should be avoided at all costs. If the patient is already on methadone, anticipate the need to increase dosage and frequency (e.g., split the total dose into twicedaily dosing) in the late second/early-third trimester due to larger plasma volume and decreased protein binding. Buprenorphine does not require dose adjustments during pregnancy. When applicable, consider initiating MAT with buprenorphine, given more widespread availability, ease of use and evidence-supported lower neonatal abstinence syndrome severity. MAT should be combined with CBT. Naltrexone is not approved for use during pregnancy and should be avoided. Stimulants: Stimulant use during pregnancy has been shown to cause intrauterine growth restriction, preterm labor, stillbirths and miscarriages, premature rupture of membranes and placental abruption. There is no specific treatment for the cessation of stimulants other than managing the patient’s symptoms along with CBT. Consider pharmacotherapy for the management of agitation and anxiety, which tend to be some of the more profound withdrawal symptoms patients will experience. Tobacco: Tobacco products are clear teratogens. They increase the risk of still birth by 1.8-2.8 times. It is estimated that onethird of sudden infant death syndrome (SIDS) may be tobacco smoking-related and may be prevented with tobacco cessation during pregnancy. Forty percent of women will quit tobacco once they learn they are pregnant. Bupropion and varenicline both should be avoided during pregnancy, leaving MAT with nicotine replacement therapy as the standard of care during pregnancy, along with CBT. Hospital Care: Continue MAT during the hospitalized timeframe. For opiate MAT, consult an experienced clinician for advice on pain control. Acutely, control pain with a strong agonist such as fentanyl at a higher than usual dose. Do not use partial agonists such as butorphanol. Drug Testing: Maternal drug testing should include Hepatitis B/C and HIV serologies as well as screening for sexually transmitted infections when indicated. Maternal drug testing should be done only with patient consent except in emergent situations. If fetal drug testing is indicated, consider cord tissue samples along

with urine toxicology rather than meconium, given the higher acquisition rate and ease of collection. Note, fetal drug testing does NOT require maternal consent. Substance

Breastfeeding Safe?

Methadone or Buprenorphine

Yes

Nicotine

Yes

Alcohol

Yes: But two hours after drinking a serving of alcohol. Per American Academy of Pediatrics (AAP), max intake of two oz. of liquor, eight oz. of wine, or two beers per day.

Cannabis

Limited data. Not recommended at this time.

Benzodiazepine

Varies by drug.

Cocaine or Amphetamines

No

Heroin

No

Phencylidine

No

Breastfeeding: A note about breastfeeding for these moms. The table below summarizes common substances and their safety with breastfeeding. Please refer to a lactation resource such as LactMed (a Toxnet database) from the National Institutes of Health (NIH) for specific drug/substance recommendations. Further Reading and References The ASAM Essentials of Addiction Medicine. https://www.asam.org/ resources/publications/essentials-of-addiction-medicine NIDA: Substance Use in Women. https://www.drugabuse.gov/ publications/research-reports/substance-use-in-women/substanceuse-while-pregnant-breastfeeding ASAM Advocacy Policy Statement: Substance Use, Misuse, and Use Disorders During and Following Pregnancy, with an Emphasis on Opioids. https://www.asam.org/advocacy/find-a-policy-statement/ view-policy-statement/public-policy-statements/2017/01/19/ substance-use-misuse-and-use-disorders-during-and-followingpregnancy-with-an-emphasis-on-opioids Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. JAMA. 2012 May 9;307(18):1934-40. doi: 10.1001/jama.2012.3951. Epub 2012 Apr 30. NIH/Toxnet LactMed. https://toxnet.nlm.nih.gov/newtoxnet/ lactmed.htm Tipu Khan, MD is Core Faculty, Ventura County Family Medicine Residency and Assistant Clinical Professor, UCLA David Geffen School of Medicine. California Family Physician Spring 2018

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addressing addiction

Matthew Varallo, DO

Family Physicians Need to Know the 21st Century Smoker The war against tobacco seems daunting and endless. Laws outlawing smoking in public places and tax legislation have helped people quit using tobacco products and deterred others from starting. But, the 21st century smoker is less likely to be just a cigarette smoker and is most likely a vaper. Vaping is the act of inhaling and exhaling the aerosol, often referred to as vapor, produced by an ENDS device (Electronic Nicotine Delivery System). Vaping is growing quickly and is here to stay. The Food and Drug Administration (FDA) estimated that in 2016 more than two million US middle and high school students used ENDS. Controversy abounds surrounding the risks and benefits of vaping. Scientists and health care providers are concerned about the unknown potential harms of putting any substance other than clean air into the lungs. Cigarette smokers and vaping stakeholders argue that vaping is a healthier alternative to smoking and may even help people quit smoking. Studies have been done evaluating both arguments; a consensus argument has yet to be formed. Ultimately time will provide the evidence. Meanwhile, we need to understand what our patients are inhaling and know the associated identified harms of vaping.

To assess the risk of vaping we must understand what is in the “juice.” The juice consists of four main ingredients: vegetable glycerin, propylene glycol, natural and artificial flavors and nicotine. •

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Vegetable Glycerin: This clear odorless liquid is usually extracted from plants through hydrolysis and usually created from coconut oil, palm oil and soy. It is also used in food

California Family Physician Spring 2018

and other household items such as: soaps, shampoos and toothpaste. Vegetable glycerin is commonly used as a food sweetener. When consumed orally the most common side effects are nausea, vomiting and headaches. Propylene Glycol: This substance is a clear colorless liquid that has a faint sweet flavor. Propylene glycol is used as a preservative in foods and in other food products such as sweeteners. It is also used in the production process for certain plastics. This compound is responsible for one of the most common side effects from vaping, throat irritation. Consider vaping in the differential diagnosis with a patient who presents with multiple episodes of non-infectious pharyngitis. The vaping industry acknowledges that propylene glycol causes throat irritation and makes both 50/50 and 80/20 juice ratios of vegetable glycerin to propylene glycol. When vaporized, propylene glycol can potentially become carcinogens such as propylene oxide, formaldehyde and acetaldehyde. Natural and Artificial Flavors: Herein lies the danger for your patients with food allergies. Imagine a scenario where your patient walks into a vape shop with juices lined along the walls and sampling tips next to the juices. The names of these juices are ambiguous: Zombie Blood, Tombstone, Twisted Cookie, Crazy Rainbow, etc. Moving from flavor to flavor your patient feels his/her throat closing up and starts to wheeze. This is a true story of a friend of mine who is allergic to coconuts and tried a Pina Colada flavored juice. It is important to educate patients about potential allergic reactions to juice ingredients; they need to ask what is in each juice before sampling. Nicotine: We know a lot about nicotine, but how people vape


it makes a big difference. The average cigarette in the US has about nine mg of nicotine in it but roughly one mg is absorbed. Juices come in a variety of strengths ranging from three mg up to 36 mg for standardized nicotine. This provides a desired nicotine delivery per hit. How a patient vapes the juice also matters when it comes to the amount of nicotine absorbed. If your patient is using an e-cigarette, which uses an atomizer/ cartomizer, to vaporize the juice he or she will absorb less nicotine because more of the nicotine is destroyed during the vaping process. If your patient is using a tank system, less nicotine will be burned and more absorbed when vaping. The high wattage drip systems are the most efficient and create the highest absorption opportunity when vaporizing juices. Asking your patient about juice strength and what system is being used provides a clearer picture to the patient’s nicotine exposure. Patients who vape all day could end up consuming more nicotine than when they were smoking cigarettes, leading to potentially higher risk of developing nicotine toxicity. Not all nicotine is absorbed, and some is exhaled into the environment, exposing people to second-hand vapor. Patients should also be on guard with young children nearby. A drink of the vape juice potentially can be fatal to a child due to nicotine toxicity. Therefore, we should discuss proper storage of the juices with our patients. The speculation and debate about vaping have only begun. Meanwhile, our patients continue to use ENDS and practice this habit. Educating patients on the risks of propylene glycol-induced throat irritation, informing at-risk patients with food allergies, performing an individual assessment of nicotine exposure through varying vaping practices and proper storage of the vape juice are essential to ensure our patients remain safe. Screening our patients for vaping and educating them about the known harms should be the next best practice in our population health mission. California Family Physician Spring 2018

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evp forum

Susan Hogeland, CAE

It’s Time to Ban Assault Weapons – Past Time Two articles came to my attention on the same day back in December, so I took it as a sign to write about the appalling gun-related massacres that have become everyday occurrences in our state and nation. I hadn’t finished writing before yet another mass-shooting took place, on Valentine’s Day, in Florida. Seventeen more students and teachers were killed with an assault rifle that to my mind, has only one appropriate use – on the battlefield. The media reported that a physician who treated some of the victims detailed their “horrific wounds” – describing organs that had been completely obliterated “like an overripe melon smashed by a sledgehammer” and exit wounds the “size of an orange,” in an op-ed piece for The Atlantic. With that kind of damage, it is hard to imagine that an AR-15 could or should be used for hunting. Yet, the NRA’s Executive Director, Wayne LaPierre, is convinced there’s a cabal waiting in the wings to take away everyone’s guns and freedom that justifies opposing every sane approach to gun ownership. The first article that came to my attention, from the New York Times of December 11, was headlined: “A 200-Year-Old Lesson on Mass Killings from Southeast Asia.” Mass killings are not, of course, a 21st Century phenomenon. According to reporter Clyde Haberman, writing about the findings of Geoffrey Robinson, a professor of Southeast Asian history and politics at the University of California, Los Angeles, 200 years ago in Malaya it was not uncommon that, “A man – it was almost always a man – would feel he had endured an unbearable indignity. After a period of brooding, he lashed out by attacking everyone in sight with knives or other sharp weapons, hacking away until fellow villagers or the authorities finally killed him.” The term “running amok” describes such an event because it was derived from the Malay word “mengamok” – “making a furious, desperate charge.” The professor thinks parallels exist between “amokers” and today’s mass killers. Fortunately, he also thinks lessons can be learned. Reporter Haberman cites an archive of 324 incidents 30

California Family Physician Spring 2018

nationwide in 2017 through November that qualify as “mayhem” (shootings in which four or more people are killed or wounded) for a total of 415 killed and 1,725 wounded. These stats are collected by Gun Violence Archive, an online tracker, because our Congress has passed legislation forbidding our own Centers for Disease Control from collecting or studying national statistics on gun violence. The budget approved by Congress as this article was being written finally provides funding for such a study. The professor’s theory on lessons to be learned – when at all possible: don’t kill the perpetrator or allow him to kill himself. In Malaya, the “aura” created by the amoker became part of the story of the village and his family; the professor likens that to the attention or notoriety that our mass murderers seek today. The heroic quality conferred on the killer disappeared in Malaya when the tactics changed – the authorities didn’t kill the killer, they arrested him and shipped him off to an institution and thereby “drained the rampage of heroic quality.” Over time, such rampages stopped. Perhaps we’ll see if this theory has some merit, since the Florida perpetrator was arrested and will be tried, as was the killer of nine at a church in Charleston, S.C. The second article was printed the same day and said the rate of gun deaths in the United States rose to about 12 per 100,000 in 2016, up from about 11/100,000 in 2015, and the second consecutive year the rate increased after a flat rate over several years. While 2017 rates hadn’t yet been compiled, the first three months of last year indicated an upward trend compared to 2016. Suicides represent the majority of gun deaths (60 percent), but the author reports that while mass killings “account for no more than 2 percent of total deaths from firearm violence, they are having an outsize effect.” They are “reshaping the character of American public life.” Indeed, they are. It would be wonderful if we could put away the conspiracy theories and start with some common sense solutions – no American outside of the military needs an assault weapon.


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