FEBRUARY EDITION, VOLUME 2017, NO. 2
MEET THE 2017 CAPITAL MEDICAL SOCIETY PRESIDENT, TRACEY HELLGREN, M.D.
Dr. Hellgren with her daughters, Emma and Hannah
CMS: Where were you born and what brought you to Tallahassee?
CMS: What prompted you to pursue medicine and specialize in primary care?
TH: I was born in Bethpage, New York, but grew up in Ft. Lauderdale, Florida. I came to Tallahassee to complete my undergraduate degree in Biology and Chemistry at Florida State University. I then went to medical school at the University of Florida College of Medicine. I was thrilled to return to Tallahassee to complete my Family Medicine Residency at the Tallahassee Memorial Family Practice Residency Program. After graduating in 1993 (and becoming a Seminoles fan for life), I joined Patients First and have worked there ever since.
TH: When I was in high school, I was not sure what I wanted to do especially following in the footsteps of a high-powered older sister and brother. My high school guidance counselor (who I still have breakfast with when I am at my mom’s) felt I was a natural born family physician. Therefore, I came to Tallahassee and the PIMS program, and decided that a career in medicine worked for me. I decided I wanted to take care of the whole being. Other specialties interested me, but I knew primary care would allow me to have a family of my own and appropriately care for my patients. CONTINUED ON PAGE 3
CAPITAL MEDICAL SOCIETY 2017 MEETINGS CALENDAR February 9, 2017 CMS Connect the Docs Whiskey Tasting hosted by Waddell & Reed Financial Advisors 5:30 - 8:00 pm LeMoyne Center for the Visual Arts
February 11, 2017 Women in Medicine Brunch 9:00 - 11:00 am Goodwood Museum Carriage House
March 30, 2017 Celebration Awards Dinner 6:30 pm FSU University Center Club
BOARD OF GOVERNORS Tracey Hellgren, M.D., President David Dixon, D.O., President-Elect
I N T H I S I SS U E :
MISSION: TO PROMOTE THE PRACTICE OF MEDICINE FOR THE ULTIMATE BENEFIT OF THE PATIENT. (850) 877-9018 Fax: (850) 878-0218 www.capmed.org
Maribel Lockwood, M.D., Secretary/Treasurer J. Daniell Rackley, M.D., Immediate Past President
Meet the New CMS President …
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New Docs on the Block …
6
Upcoming CMS Events …
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Announcements …
8
CMS Lunch and Learn …
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2017 Celebration Awards Dinner …
10
Reflections from the Editor …
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CME Opportunity …
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2017 CMS Foundation Board of Directors …
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CMS Foundation …
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CMS Foundation: We Care Network …
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Christie Alexander, M.D. Rohan Joseph, M.D. Narayanan Krishnamoorthy, M.D. Paresh Patel, M.D.
HAPPY BIRTHDAY!
Gregory Perry, M.D. Laurence Rosenberg, M.D.
{FEBRUARY BIRTHDAYS}
Ida Thompson, President, CMS Alliance Ernesto Umaña, M.D. Julia Weeks, M.D. Kenneth Whithaus, M.D.
Robert Steinmetz, M.D. – 1st
Krista Rankin, M.D. – 10th
Pam Irwin, Executive Director, Capital Medical Society
Bert Morales, M.D. – 2nd
Jeannine Silberman, M.D. – 10th
Family Medicine Residents Todd Hewitt, M.D./Meredith Maxwell, M.D.
David O’Bryan, M.D. – 2nd
Satish Mital, M.D. – 11th
Brian Sherman, M.D. – 3rd
William Simmons, M.D. – 14th
C. Raymond Cottrell, M.D. – 4th
Kenneth Kato, M.D. – 15th
Shakra Junejo, M.D. – 6th
Chris DeRosier, M.D. – 16th
Anahita Sanaie, M.D. – 6th
Garrison Rolle, M.D. – 16th
Wade Douglas, M.D. – 7th
Robert Snyder, M.D. – 16th
Donald Loucks, M.D. – 7th
Robert Atwater, M.D. – 18th
James O’Neill, M.D. – 7th
Narlito Cruz, M.D. – 19th
Stephen Quintero, M.D. – 7th
Meredith McKinney, M.D. – 19th
William Thompson, M.D. – 7th
Teresa Skojac, M.D. – 20th
Graham Whitaker, M.D. – 7th
Jerry Ford, M.D. – 21st
Frank Gredler, M.D. – 8th
Joseph Camps, M.D. – 22nd
John MacKay, M.D. – 8th
James Geissinger, Jr., M.D. – 23rd
Michael Cavallaro, M.D. – 9th
Joseph Baker, M.D. – 26th
Larry Harper, M.D. – 10th
Gregory Albright, D.O. – 28th
Internal Medicine Residents Vishal Dahya, M.D./Rachel Russell, M.D. General Surgery Residents Emanuela Alvarenga, M.D./Paul Clark, M.D.
PUBLICATION EDITOR Frank Skilling, M.D.
MANAGING EDITOR Shannon Boyle
GRAPHIC DESIGN Gandy Printers
EDITOR EMERITUS Charles E. Moore, M.D.
ARE YOU INTERESTED IN WRITING AN ARTICLE FOR CAP SCAN?
Please contact Shannon Boyle at sboyle@capmed.org. All articles submitted will be reviewed by your peers prior to publishing. Cap Scan is published during the first week of each month and is the official publication of the Capital Medical Society. Advertising in Cap Scan does not imply approval or endorsement by the Capital Medical Society. The opinions expressed are those of the individual authors and do not necessarily reflect the official policies of the Capital Medical Society.
HAPPY BIRTHDAY! WE ARE SO GLAD YOU WERE BORN!
If you are a member of the Capital Medical Society and would like a copy of the Minutes from the Board of Governors meeting, please call the CMS office. Thank you. 2
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
DID WE MISS YOUR BIRTHDAY? IF SO, PLEASE EMAIL ROSALIE CARLIN AT RCARLIN@CAPMED.ORG!
MEET THE NEW CMS PRESIDENT
CMS: What do you like best about being a physician? TH: I really enjoy caring for the whole family unit. My patients have become part of my medical family. I can feel their pain and see their joy. I help a variety of ages and get to do procedures and direct care to the next level of treatment. I also have truly enjoyed working with residents and medical students. One of my favorite quotes is, “To teach is to learn all over again,” and I am lucky enough to be able to teach and learn from our future medical doctors. CMS: What do you feel are the challenges facing medicine? TH: Given my specialty, I worry about the future of primary care. Patients need a medical home. The lack of medical students expressing an interest in primary care is worrisome. How do we encourage medical students to go into primary care? That is the question I ask myself every day and hope to answer before it’s too late. Another challenge is physician reimbursement. Physicians need to be appropriately reimbursed for what we do to care for our patients, and
that presently is not happening. New doctors are heading toward specialty areas or the ER/ Hospitalist career paths, so that they can potentially work less hours, make a good salary to support a family and pay off loans, and go home at the end of the day finished. CMS: Please tell us about your family. TH: I have two daughters: Emma (13) is in eighth grade at Holy Comforter Episcopal School, and Hannah (17) is a senior at Leon High School and is currently looking at colleges. My mom still lives in Ft. Lauderdale where I grew up. I have two siblings: my brother lives in Gainesville, Florida and is a Wildlife Biology Professor at UF, and my sister lives in California and is an Electrical Engineer. CMS: How do you spend your free time? TH: I enjoy cooking, making jam, traveling (I have traveled to Eastern, Western, and Central Canada, most of the East and West Coast of the U.S., Alaska, Europe, and Great Britain), FSU events and FSU football, family time, and most of all, spending time with my daughters.
Dennis A. Fried, M.D., J.D.
Licensing, Discipline & Peer Review Defense for All Medical Professionals in Florida Free Initial Consultation Blanchard, Merriam, Adel & Kirkland, P.A. 4 S.E. Broadway Street, Ocala, FL 34471 352-732-7218
www.bmaklaw.com CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 3
ANNOUNCEMENTS
ANNOUNCEMENTS
Dr. Rohan Joseph and his wife, Elizabeth welcomed their second child on December 16, 2016. Zoe Karen weighed 8 pounds 9 ounces and measured 21 inches long. Zoe Karen joins big brother, Zachary. Congratulations to the Joseph family!
Michael Davino and Tim Dean We thank Waddell & Reed Financial Advisors for sponsoring the January 10th CMS Board Dinner at Table 23.
#PamandEdGetWed! On Thursday, December 29, Pam Wilson, Executive Director for Capital Medical Society was married to Edward P. Irwin of Dothan, Alabama. The wedding and reception were held in Fairhope, Alabama. Edward works for the Georgia Department of Public Health. The couple will reside in Tallahassee, Florida. On behalf of the Capital Medical Society, we wish Edward and Pam Irwin all the best and a wonderful life together. Pam’s new email address is pirwin@capmed.org.
2017
TA L L A H A S S E E M E MOR I A L
C A R D I O VA S C U L A R S Y M P O S I U M S AV E T H E D AT E FEBRUARY 24 & 25 Florida State Conference Center 555 W Pensacola Street | Tallahassee, Florida Join us for two days of educational lectures on clinical guidelines and current and emerging evidence-based treatment options in cardiovascular care. Featuring A-Z Guide to Adult Congenital Heart Disease by Anurag Sahu, MD, Emory Healthcare & Emory University School of Medicine. Physicians | $275 Physician Assistants & Nurse Practitioners | $175 This activity has been approved for AMA PRA Category 1 Credit™ Learn more and register at TMH.ORG/HeartSymposium Or call 850-431-2727
4
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
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CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
5
NEW DOCS ON THE BLOCK
NEW DOCS ON THE BLOCK Capital Medical Society welcomes our newest members: Robert A. Kickish, M.D. Medical School: George Washington University Internship/Residency: University of South Florida Practice: North Florida Pediatrics Specialty: Pediatrics
Justin “Mac” Vining, M.D. Medical School: Medical College of Georgia Internship/Residency: Medical College of Georgia Fellowship: Medical College of Georgia Practice: Wolfson Children’s Specialty Services Specialty: Pediatric Cardiology
Capital Capital Nephrology Nephrology Clinic, Clinic, P.A. P.A.
Center Center for for Kidney Kidney Care Care & Hypertension Hypertension & Hiren Hiren J. J. Joshi, Joshi, M.D. M.D. Now Accepting New Patients Services • Chronic Kidney Disease • Hypertension • Dialysis Care • Kidney transplant care • Proteinuria • Hematuria
1641 Mahan Center Blvd, Suite #2 • Tallahassee, FL 32308 Phone (850) 999-2328 • Fax (850) 320-6114 6
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
UPCOMING CMS EVENTS
Whiskey Tasting February 9, 2017 • 5:30 – 8:00 pm LeMoyne Center for the Visual Arts Connect with other members of the Capital Medical Society at our FIRST ever Connect the Docs Whiskey Tasting. Bring a family member or colleague to join in on the fun. Please remember that all guests must be 21+. Please RSVP as soon as possible to Shannon Boyle at sboyle@capmed.org.
Hosted by
Save The Date - Society February 11, 2017a Capital Medical presents
Women in Medicine Brunch Save The Date - February 11, 2017
February 11, 2017 Guest Speaker: 9:00 a.m. - 11:00 a.m. – Goodwood Carriage House Rebekah Bernard, M.D. CMS Members and CMS Alliance Members are invited “Taking Back Control: Prevention and Treatment of Physician Burnout” Guest Speaker:
Women in Medicine Brunch 9:00 a.m.- 11:00 a.m. – Goodwood Carriage House
Rebekah Bernard, M.D. Rebekah Bernard, M.D. Guest Speaker: “Taking Back Control: Prevention and Treatment of Physician Burnout” 9:00 a.m.- 11:00 a.m. – Goodwood Carriage House “Taking Back Control: Prevention and Treatment of Physician Burnout”
Dr. Rebekah Bernard, author of HowBernard, to Be Aauthor Rock of Star Doctor, a practicing primary care physician in Collier County, Florida. Come help us celebrate women in Dr. Rebekah How to Be AisRock Star Doctor, is a practicing primary care physician in Collier County, Florida. Dr. by Rebekah Bernard, author How Becontrol A Rock Star is of aprofession practicing primary care physician Comeof join us toto learn how you can take Doctor, back control your life and your profession in celebration of in Collier County, Florida. medicine joining National us to learn how you can take back ofearlier, your life andlessyour indocumentation, celebration ofand National Women in Medicine Day. Get out of work Women in Medicine Day. Get out of work spend time on needless make your patients happier Come join us to learn how you can take back control of your life and your profession in celebration by of following the rules of Rock Star physicians. Getyour the most out ofhappier each patient encounter,the maximizing profit while improving patient earlier, spend less time on needless documentation, and make patients by following rules of “Rock Star” physicians. Get the most out of each by National Women in Medicine Day. Get outsatisfaction, of work earlier, spend lessfrom time on needless documentation, and make your patients happier and protecting yourself burnout and compassion fatigue. patient encounter, maximizing profit while Get improving patient and protecting yourself from burnoutprofit and compassion fatigue. patient following the rules of Rock Star physicians. the most outsatisfaction, of each patient encounter, maximizing while improving Invitations will be emailed early January. satisfaction, and protecting yourself from inburnout and compassion fatigue.
Cost: $15 per person Event Sponsor:
Supporting Sponsor: SunTrust
MagMutual
Invitations will be emailed in early January.
RSVP as soon as possible to Rosalie Carlin at rcarlin@capmed.org or 877-9018. Supporting Sponsor: SunTrust
Supporting Sponsor: SunTrust
Event Sponsor: MagMutual Event Sponsor: MagMutual
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 7
ANNOUNCEMENTS
e e s s e a e h s a s l l a e a l h e l T a s l TaallHlashsaiittsAAllll T Ha s it A Ha
Great schools, lovely weather, big-time college sports, and Southern Charm. Great schools, lovely weather, big-time You can sports, add world cancerCharm. care to the list. college andclass Southern Great schools, lovely weather, big-time Florida Specialists is the largest You canCancer add world class cancer care toprivate the list. college sports, and Southern Charm. Medical practice in cancer thethe country with Florida Cancer Specialists is largest private YouOncology can add world class care to theover list. 100 cancer centers in Florida, and two cancer centers here in Medical Oncology practice in the country with over Florida Cancer Specialists is the largest private Tallahassee. We100 offer patients everyinOncology single FDAand approved cancer treatment cancer centers Florida, two in cancer centers here over in Medical practice the country with every singleWe day.offer Every one. centers Immunotherapy, vaccine therapy, chemotherapy, Tallahassee. patients every single FDA approved cancer treatment 100 cancer in Florida, and two cancer centers here in monoclonal antibodies, along with molecular profiling and, of every single day. Immunotherapy, vaccine therapy, chemotherapy, Tallahassee. WeEvery offer one. patients everypersonalized single FDA approved cancer treatment course, clinical ofalong novelImmunotherapy, agents. So your patients can getprofiling thechemotherapy, careand, they of monoclonal antibodies, with personalized molecular every single day.trials Every one. vaccine therapy, need in the town they love. course, clinical trials of novel agents. So your patients can getprofiling the careand, theyof monoclonal antibodies, along with personalized molecular need in the town trials they love. course, clinical of novel agents. So your patients can get the care they need in the town they love.
Scott Tetreault, M.D. v Viral Bhanderi, M.D. v Parakeshkumar Patel, M.D. Scott Tetreault, M.D. v Viral Bhanderi, M.D. v Parakeshkumar Patel, M.D. 2626 Care Dr Scott Tetreault, M.D. v Viral Bhanderi, M.D. v Parakeshkumar Patel, M.D. SuiteCare 200 Dr 2626 Tallahassee 32308 SuiteCare 200 2626 Dr v Tallahassee 32308 Suite 200 1600 Phillips Dr v 32308 Tallahassee Suite300 1600 Phillips Dr v Tallahassee 32308 Suite300 1600 Phillips Dr v 32308 Tallahassee Suite300 (850) 219-5830 v 32308 Tallahassee Fax(850) (850)219-5830 671-1251 v Fax(850) (850)219-5830 671-1251 Fax (850) 671-1251 8
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
CMS LUNCH AND LEARN
CAPITAL MEDICAL SOCIETY LUNCH AND LEARN SEMINARS SPRING 2017
February 15, 2017 MACRA: Earn It or Lose It! The stakes are high as reimbursement models continue to evolve. Whether the Affordable Care Act stays or goes, in part or in totality, experts across the board agree that focusing on quality and health outcomes is one of the best ways to improve long-term healthcare economics in the United States. Getting on board with the latest alphabet soup – MACRA, MIPS, QPP – is the best plan for long-term success. And, no, before you ask – Meaningful Use is not going away! The AHIT team will give participants the highlights they need to understand surviving one of the latest healthcare reimbursement adventures!
March 15, 2017 Cybersecurity, Identity Theft, and Your Practice Cybersecurity is a term you hear more frequently in the news – from reports on election hacking, electric utilities, to ransomware…But how does this affect you, your office, and your role and potential liability? This 90 slide presentation covers local events, how they impacted local businesses, and how to minimize the risk you’ll be next.
Speakers: The Center for the Advancement of Health IT team - Diane Gaddis, President/CEO; Chantal Laperle, Director of Quality Improvement and Care Transformation; and April Zehms-Payne, Practice Advisor
April 19, 2017 ACA Updates Speaker: Gary Pickel, Brown & Brown Insurance
Speaker: Ben Graybar, Hancock Bank Sponsor: Diana Cureton, Hancock Bank
Sponsor: Greg Jaap, Brown & Brown Insurance
Sponsor: Traci Poucher, Campus USA Credit Union May 17, 2017 The Do’s and Don’ts of Patient Communication Speakers: Lon’Tejuana Cooper, Ph.D., MHA, RHIA, CPM and Marjorie H. McNeill, Ph.D., RHIA, CCS, FAHIMA Sponsor: Tony Shah, Express Printing
Time: 12 Noon to 1:30 PM (Seminars start at 12:30 PM) Place: CHP Auditorium, 2nd Floor, 1491 Governors Square Blvd. Cost: $10 per person, per seminar
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 9
2017 CELEBRATION AWARDS DINNER
MARK YOUR CALENDAR FOR THE 16TH ANNUAL CELEBRATION AWARDS DINNER Celebrate the profession of medicine with your colleagues! Mark your calendars for the Capital Medical Society’s annual Celebration Awards Dinner on Thursday, March 30th at 6:30 pm at the University Center Club at Florida State University. Our Celebration Awards Dinner honors Doctors’ Day, which is on March 30th every year. An exciting part of this event is the presentation of two prestigious awards. The I.B. Harrison, M.D. Humanitarian Award will recognize a local physician’s humanitarian effort to help patients. The Outstanding Physician Award will recognize a local physician’s effort to help the profession of medicine. The 2017 winners will be announced in early February. Invitations will be sent in early March. We hope to see you there!
CAPITAL MEDICAL SOCIETY 2017 MEETINGS CALENDAR (continued from page 1)
April 18, 2017 CMS Membership & Educational Meeting (no CME credit) 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks May 16, 2017 CMS Membership & CME Meeting 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks
May 2017 CMS Family Night Time & Location: TBA September 19, 2017 CMS Membership & CME Meeting 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks October 17, 2017 CMS Membership & CME Meeting 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks
10 CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
November 7, 2017 CMS Membership & CME Meeting 6:00 pm Maguire Center for Lifelong Learning at Westminster Oaks December 7, 2017 CMS Foundation Holiday Auction 6:30 pm FSU University Center Club
REFLECTIONS FROM THE EDITOR
MY 45 YEARS IN MEDICINE By Frank Skilling, M.D.
“The more things change, the more they remain the same.” A. Karr With the position of editorship of Cap Scan, I now claim a point of personal privilege in looking back at what I perceive as the major changes I’ve noted in the field of medicine (not “healthcare” as it’s come to be called) since I graduated from the University of Alabama in Birmingham School of Medicine in 1972. I point out that these are my observations and my opinions, and if I was writing this at another time the listings might be different, but not vastly so. The most obvious change as I look at my graduating class in my yearbook is that less than 5% of seniors that year were women. Today, that number is 50 to 60%. My initial class was 100 students. Four years later, 95 white men, 2 white women, and one black man marched across the stage to become medical doctors. This year’s graduating class at FSU College of Medicine was approximately 50% female with a large percentage of minority students, and UAB had a similar mix. In 1967, a woman who was a good friend of mine applied to medical school and was roundly rejected despite an excellent undergraduate record and high
standardized test scores. When an inquiry was made why she would not get in, a male admissions director announced, “She’s good looking; she’s going to get married; she’s going to get pregnant, and she’s going to drop out of medical school. Therefore, she’s not going to be accepted by us.” Such chauvinism, open discrimination and prejudice are obviously illegal now. Family medicine as a specialty has undergone a gigantic change. Prior to 1975 there were no recognized board requirements for family practice. Physicians in most states could finish an internship (now called post graduate year one), secure an office, hang out a shingle, and start practicing however they wished. Once the American Board of Family Medicine was incorporated, the requirements for admission were formalized and family practice joined the ranks organized medicine. Hospitals too started to require certification to be a family practitioner on staff, and many healthcare organizations, especially HMOs, began to use these physicians as “gatekeepers” for entry. The changing roles of medical specialties have accelerated the progression of medical care. Diagnostic radiology, as I recall, was a field that relied on “looking back” at how medical
care was delivered. Yes, there were procedures that were done in the radiology departments of hospitals like barium enemas, but many radiologists spent their days reviewing films in darkened rooms with multiple screens while dictating notes for the patient chart. Today, radiologists are an integral part of the diagnostic team working in “real time” by providing CT guided biopsies through transcutaneous or vascular entries. Patients often spend more time with diagnostic radiologists who can provide non-surgical access to their particular problem. An acquaintance recently had closure of a cerebral aneurysm with a “coil” placed by a radiologist who worked through a catheter placed in his groin. Mammography has opened a whole sub-specialty in the field that transcends diagnosis and treatment in ways never dreamed of in the early 1970s. With CT scanners and MRI machines next to emergency departments, on call radiologists may not be able to rest while on duty. General surgery itself has been transformed from a field that had wards of pre- and post-operative patients who were anticipating or recovering from major procedures to an outpatient field where patients are often discharged within twenty-four hours of having an operation. Prompt CONTINUED ON NEXT PAGE
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 11
REFLECTIONS FROM THE EDITOR
ambulation and intensive care units have allowed even “high risk” patients to undergo procedures that were previously treacherous. The emergency room has been transformed from a fancy triage unit in some hospitals to the point of treatment for many patients. When I was the overnight physician in an ER in Pensacola in the mid-70s, I rarely ordered more than routine blood work and X-rays on patients before they were admitted for definitive care. Now CT scans are performed, central venous lines placed and blood clots in the brain are dissolved within minutes of patients crossing the threshold of the ER. Here is another new specialty that like family medicine was unrecognized on its own when I graduated in 1972. Rather than being staffed by semi-retired physicians, today’s ERs are filled with trauma and critical care specialists, the “fighter pilots” of medicine. The role of “physician expanders” has greatly increased efficiency in clinical settings. My first encounter with them was when I served as a Navy medical officer with a Marine infantry battalion. As a young physician I often supervised several Navy Corpsmen who were trained to provide first aid in the field, work in outpatient clinics and assist in surgical procedures. Many were veterans of the Vietnam War and were more skilled than I was in providing first aid and stabilization of critically injured patients. One of my close friends, a Marine Captain, was saved by a corpsman who threaded a section of IV tubing into his femoral artery after it was severed 12
by a piece of shrapnel. His leg was saved, and he even returned to active duty as an infantry officer. After I was discharged, I was glad to find that their civilian counterparts were coming online as physician assistants (PAs) and nurse practitioners (ARNPs). I don’t think anyone in medicine now can conceive of a rational delivery system that doesn’t include them. The career path now provides bright young people with the opportunity to work with physicians who provide backup support for them. The FSU College of Medicine is starting a PA program this year and already has had over 800 applicants before its doors are opened. While hospital costs have continued to escalate, the rise of outpatient medicine has changed the algorithms for providing medical care. I can remember the era when physicians would admit patients for a diagnostic work-up that lasted three to five days and often resulted in no definitive recommendations. Today patients have multiple procedures done without spending the night in a hospital. Thanks to improved anesthesia care, outpatient surgery has become the norm. I did the first strabismus operation on a child at a Tallahassee outpatient facility in 1980, and afterwards I worried most of the night if the child was going to do well without the supervision of a pediatric hospital nurse. He looked and acted fine the next day, and I never considered doing in-patient pediatric eye surgery again unless it was absolutely necessary. When I consider that we used to admit patients for five to seven days for
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
cataract surgery, I have to ask myself just what did we for those patient’s post-op that they could not do for themselves at home. Many studies have shown that the long term outcomes are as good as or better than in-patient surgery. No surgery is risk free, but most people prefer to sleep in their own beds and eat food they are accustomed to. The internet has been such a huge change over the past fifteen years in how medicine is practiced that it’s hard to conceive how we could survive without it. Just consider making appointments for routine lab work: if you have a computer with internet access you can arrange the date and time for your lab work without ever having to directly contact another human. Patients are given access to their hospital records and health information without having to physically find a chart, copy it and then decipher its information. Of course, the down side is that patients have become their own diagnosticians and treaters, and they sometimes show up requesting a specific course of action without finding out if it’s appropriate for them. (Do you ever wonder why the pharmaceutical companies spend so much on advertising on the evening news hour?) Next month: What’s on the horizon for medicine? CMS
CME OPPORTUNITY
CME OPPORTUNITY Reprinted with permission from the Duval County Medical Society (DCMS) Title of Enduring Material: Responsible Opioid Prescribing Needs Assessment: The Duval County Medical Society (DCMS) strives to provide its members with benefits that consistently meet their professional needs, which includes providing Continuing Medical Education opportunities. There has been an epidemic of prescription drug abuse over recent years, mostly spawned in Florida by licensed physicians. A disastrous outcome in morbidity and mortality has led to a reformulation of medical practice guidelines and legal statutory regulations. Responsible prescribing requires an understanding of opioid pharmacology, knowledge of the medical standard of care, familiarity with the applicable Florida statutes, and practicing due diligence in preventing abuse and diversion. Faculty & Credentials: Timothy Sternberg, DMD, MD, Spine Care & Pain Management, Ancora Pain Recovery Learning Objectives: Upon completion of this enduring material, participants will be able to:
• Understand the epidemiology of opioid prescription abuse. • Have a general knowledge of the risks, benefits, and limitations of chronic opioid therapy. • Be acquainted with the applicable Florida Statutes regarding prescribing chronic opioids. • Be informed enough of the standard of care for chronic opioid prescribing to come to a personal decision whether you would want this to be a part of your professional practice.
Date of release: September 1, 2016
Date credit expires: September 1, 2018
Estimated time to complete the activity: 2.0 Hour
Medium or combination of media used: Medical Journal - Northeast Florida Medicine Method of Physician Participation in the Learning Process:
1. Read the “Responsible Opioid Prescribing” article on page 14. 2. Complete posttest following the article and mail to the DCMS at 1301 Riverplace Blvd., Ste. 1638, Jacksonville, FL 32207. 3. If you are not a DCMS member, please include a $55 check to the Duval County Medical Society. All non-members must submit payment for their CME before their test can be graded.
CME Credit Eligibility: In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if a passing score is not made on the first attempt. DCMS members have two years to submit the posttest and earn CME credit. Return the posttest and completed evaluation form to: DCMS, 1301 Riverplace Blvd., Ste. 1638, Jacksonville, FL 32207. A certificate of credit/completion will be emailed (or mailed for those w/o email) within 2 weeks of submission. If you have questions, please contact Kristy Wolski at (904) 355-6561, or kristy@dcmsonline.org. Disclosure of Conflicts of Interest: St. Vincent’s HealthCare (SVHC) requires speakers, faculty, CME Committee, and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations. Speaker Disclosure Information: Timothy Sternberg, DMD, MD reports that he has no significant relationships to disclose, financial or otherwise, with any commercial supporter or product manufacturer associated with this activity. Timothy Sternberg, DMD, MD also reports that his article will not include discussion of any investigational or unlabeled use of a product. Joint Sponsorship Accreditation Statement: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of St. Vincent’s HealthCare and the Duval County Medical Society. The St. Vincent’s HealthCare (SVHC) is accredited by the Florida Medical Association to provide continuing medical education for physicians. The St. Vincent’s HealthCare (SVHC) designates this educational activity for a maximum of 2.0 category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity. CONTINUED ON NEXT PAGE
CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION 13
CME OPPORTUNITY
Responsible Opioid Prescribing By Timothy Sternberg, DMD, MD Abstract: Prescription drug abuse has become an epidemic in recent years, often facilitated in Florida by licensed physicians. Disastrous outcomes resulting from this abuse have led to a reformulation of local, statewide and national medical practice guidelines and legal statutory regulations in order to decrease morbidity and mortality. Responsible prescribing requires an understanding of opioid pharmacology, knowledge of the medical standard of care, familiarity with the applicable Florida Statutes, and diligence in preventing abuse and diversion. Introduction: In the 1990s, appropriate management of pain became an accepted clinical goal by physicians and a medical-moral imperative by public demand. The prevailing thought among experts in the field was that opioid analgesics were being inappropriately withheld from patients suffering from chronic pain. Long accepted as appropriate medical therapy for the treatment of acute, postoperative and cancer pain, opioids then were touted as medically indicated for chronic pain regardless of etiology. Early clinical dosing guidelines implied that the opioid dose should be titrated up until an appropriate clinical response (acceptable pain control per patients’ self-report) or a dose limiting adverse drug effect (ADE) was achieved, since there was felt to be no true organ toxicity with chronic exposure. Consequently, opioid prescribing climbed sharply, simultaneously increasing supply and demand.1 This greater access led to patients with legitimate clinical needs and individuals seeking opioid-induced euphoria being increasingly exposed to easily available narcotics. In 2010, enough opioids were sold in the United States to medicate every American adult with 5 mg of hydrocodone every four hours for one month.1 There arose in Florida a particular group of physicians, misguided at best, who started cash only self-described “pain clinics” (more commonly referred to as “pill mills”), and prescribed and dispensed inordinate amounts of opioids (mostly oxycodone) and benzodiazepines (mostly alprazolam). At one time, there was more oxycodone (both mg amount and numbers of prescriptions) dispensed in Florida than in the entire United States and 80 percent of this was from Broward County.1 Opioid sales in Florida in 2008-2009 were the highest in the nation at 12.6 kg per 10,000 citizens.1 Pill mills rapidly spread throughout Florida which became a pipeline for oxycodone into Kentucky, Ohio and many areas of the United States.2 From 1999-2008, opioid overdose death rates, sales, and substance abuse treatment admissions increased in parallel.1 The incidence of death secondary to overdose of narcotics increased yearly from 2000-2010. In 2007, nearly 100 persons died per day of drug overdoses in the United States.1 The overdose death rate in 2007 was roughly three times the rate in 1991, mostly from prescription opioids.3 In 2010, 4.8 percent of the U.S. population above the age of 12 used opioids non-medically.4 In Florida, the overall opioid overdose death rate per 100,000 was 16.5, significantly above the national rate of 11.9.1 Florida’s death rate for prescription drugs increased 84.2 percent from 2003 to 2009, with the greatest increase observed for oxycodone (264.6 percent), followed by alprazolam (233.8 percent).5 Though touted, and heavily marketed, as effective therapy for chronic pain, evidence for the benefit of chronic opioid therapy for non-malignant pain is
limited. A Cochrane Review concluded evidence that long-term opioid therapy produced significant pain relief was weak, and evidence for improvement of quality of life or functioning was inconclusive.6 Additionally, evidence that high dose opioids or controlled release opioids are any more beneficial than low dose short acting opioids is lacking.7 In response to the plethora of “pill mill” physicians unnecessarily prescribing and dispensing large amounts of narcotics, the Florida Legislature acted. In 2010, laws were enacted that required “pain clinics” to register with the state and have a physician owner. The laws also established prescribing and dispensing requirements. In 2011, despite initial opposition from Governor Rick Scott, the state’s Prescription Drug Monitoring Program (PDMP) became operational. To responsibly prescribe opioids, physicians must understand the aforementioned problems associated with opioids, their benefit versus risk, the current standard of care, and the applicable Florida Statutes. Opioid Analgesics: Opioids are the most potent analgesics for acute pain. They work as agonists on opioid receptors (mostly mu, but also kappa, sigma, and delta) in the central nervous system. Besides analgesia, other potential benefits may include sedation, cough suppression, and relief of dyspnea. The most commonly prescribed opioids are oxycodone and hydrocodone. Predictable adverse drug effects (ADE’s) of opioids, when used on a short term basis, are respiratory depression, orthostatic hypotension, nausea, vomiting, constipation, urinary retention, pruritus, and meiosis. Opioid overdose deaths are usually due to hypoxemia from respiratory arrest. When used on an intermediate term and chronic basis, predictable ADE’s are constipation, tolerance (requiring increased dosing for same clinical benefit), and physical dependence (characterized by abstinence syndrome with abrupt discontinuation). Other common ADE’s are xerostomia, sweating, somnolence, disrupted sleep cycle, and hypogonadotropic hypogonadism with sexual dysfunction.8 A potential ADE, especially when used for non-medical purposes and even a small risk when used properly, is addiction (biopsychosocial disorder characterized by compulsive use despite harm). Medical Standard of Care: There are several practice guidelines on opioid therapy from pain management and other medical associations.9,10 Most guidelines for responsible opioid prescribing reflect common sense medical care, and include: patient history and physical examination, abuse risk assessment, determination of clinical goals, a treatment plan, informed consent, medication selection, outcome measurement, monitoring side effects, consideration of alternative strategies, and proper documentation. This practice is consistent with the “Universal Precautions” as applied to opioid prescribing (Table 1).11 In 2016, the Centers for Diseases Control and Prevention also issued an opioid prescribing guideline, providing recommendations for primary care clinicians prescribing opioids for chronic non-malignant pain.12
Address correspondence to: Timothy Sternberg, DMD, MD, Spine Care & Pain Management/Ancora Pain Recovery 3 Shircliff Way, Suite 521, Dillon Professional Building, SVMC, Jacksonville, FL 32204 • (904) 479-0707 14 CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
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___________________________________________________________________
___________________________________________________________________
Table 1: Universal precautions as applied to opioid prescribing
Table 2: Opioid Risk Tool13
1
1. Make a diagnosis with an appropriate differential. 2. Conduct a patient assessment, including risk for substance use disorders. 3. Discuss the proposed treatment plan with the patient and obtain informed consent. 4. Have a written treatment agreement that sets forth the expectations and obligations of both the patient and the treating physician. 5. Initiate an appropriate trial of opioid therapy, with or without adjunctive medications. 6. Perform regular assessments of pain and function. 7. Reassess the patient’s pain score and level of function. 8. Regularly evaluate the patient in terms of the “5 A’s”: Analgesia, Activity, Adverse effects, Aberrant behaviors, and Affect. 9. Periodically review the pain diagnosis and any comorbid conditions, including substance use disorders, and adjust the treatment regimen accordingly. 10. Keep careful and complete records of the initial evaluation and each follow up visit Used with permission of D. Gourlay __________________________________________________________________ History: The patient’s history is particularly important when evaluating for opioid therapy. The nature of the pain must be investigated. Does this patient have a pain that is amenable to opioid analgesia? Generally, acute moderate to severe pain due to trauma or surgery is effectively controlled with opioids. Nociceptive somatic pain (due to real or impending tissue damage) is more effectively treated with opioids than neuropathic pain (due to neural damage or dysfunction). For chronic nociceptive pain due to musculoskeletal disorders (the most common indication for long term opioid therapy), opioid benefit can be real though modest. An important aspect of the patient’s history is the use of benzodiazepines, which increases risk of overdose with concurrent use of opioids.12 Risk is also increased in elderly patients and those with sleepdisordered breathing, renal impairment, or hepatic insufficiency.12 Physical examination: Is the patient irritable? Are the pupils overly constricted or dilated relative to ambient light? Does the patient perseverate in asking about pain medications? Are there smoke stains on teeth or fingers? Are there tract marks in skin overlying veins? Is there tremor unexplained by known neurological disease? Risk Assessment: The patient must be evaluated for risk of opioid abuse and/or diversion. Elements that increase risk of abuse are a history of mental illness, incarceration, alcohol abuse, drug of abuse (DOA), smoking, long term unemployment, and noncompliance with previous narcotic therapy. Older adolescents and young adults have a higher risk than those older than 45 years. There are several validated instruments of variable length available to evaluate risk. A practical one is the Opioid Risk Tool (Table 2), a five item questionnaire exploring the patient’s personal and/or family history of substance abuse, age, history of preadolescent sexual abuse, and psychological disease.13
Date _____________________________ Patient Name ________________________________
OPIOID RISK TOOL© Mark each box that applies
Item Score If Female
Item Score If Male
1. Family History of Substance Abuse
Alcohol Illegal Drugs Prescription Drugs
[ [ [
] ] ]
1 2 4
3 3 4
2. Personal History of Substance Abuse
Alcohol Illegal Drugs Prescription Drugs
[ [ [
] ] ]
3 4 5
3 4 5
3. Age (Mark box if 16 – 45)
[
]
1
1
4. History of Preadolescent Sexual Abuse
[
]
3
0
]
2
2
[
]
1
1
[
]
5. Psychological Disease
Attention Deficit Disorder [ Obsessive Compulsive Disorder Bipolar Schizophrenia Depression
TOTAL Total Score Risk Category
Low Risk 0 – 3
Moderate Risk 4 – 7
High Risk > 8
Used with permission: Webster LR, Webster R. Predicting aberrant behaviors in Opioid-treated patients: preliminary validation of the Opioid risk tool. Pain Med. 2005;6(6):432. Webster LR, Webster R. Predicting aberrant behaviors in Opioid-treated ___________________________________________________________________ patients: preliminary validation of the Opioid risk tool. Pain Med. 2005;6(6):432
Treatment goals: Goals of therapy should be established prior to initiating treatment. For opioids to be considered effective, analgesia must be accompanied by improved functioning. Expected analgesia from opioids for chronic pain must be explained explicitly: modest. When effective, opioids may reduce the patient’s self-assessed pain score 2-3 points on a 10-point scale. The patient must understand that eliminating the pain entirely is unobtainable, even contraindicated. Seldom do opioids, by themselves, adequately control pain. Analgesics should be one part of a comprehensive pain management strategy, which usually includes a physical therapy or home exercise program, a cognitive readjustment, and consideration of interventional therapies Informed Consent: Besides a physician-patient discussion, there should also be a written, signed, and maintained opioid agreement, consent, or “contract.” Though there are many available, including templates in some EHR’s, the basic elements are similar. The patient agrees to: the risks and benefits of opioid therapy; obtaining all prescription analgesics from one source, no DOA, no diversion (selling, trading, and giving away), non-replacement of lost, stolen, and misplaced drugs, compliance testing, and an understanding when opioids would be tapered and discontinued. Medication Selection: The most commonly used outpatient opioids, in approximate order of potency, are: tramadol < codeine < tapentadol < hydrocodone/morphine < oxycodone < oxymorphone < methadone < hydromorphone < fentanyl. Tramadol (Ultram) can be an effective analgesic when non-opioid analgesics fail to provide adequate relief and, since it is a Schedule IV drug, multiple refills can be written. Codeine, combined with acetaminophen, is a weak analgesic; though chronic use is limited by excess constipation relative to analgesia. Tapentadol (Nucynta) is somewhat stronger than tramadol; however DEA classification as a Schedule II drug prohibits refills. Hydrocodone (Norco, Zohydro) was changed by the DEA to a Schedule II drug in 2013; though it remains the most commonly prescribed opioid. Oxycodone (Percocet, CONTINUED ON NEXT PAGE
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Oxycontin) is the second most commonly prescribed. Generics are available for both. Oxymorphone (Opana) and hydromorphone (Dilaudid) are stronger and also available as extended release formulations, Opana ER and Exalgo, respectively. Methadone is an effective and inexpensive long acting opioid but requires a slow titration, can be associated with prolonged QT induced arrhythmias, and is best left to those experienced with its dosing. Fentanyl is very potent and available as transdermal patch (Duragesic) and transmucosal (Actiq, Fentora). Besides the relative potency, the choice of an immediate versus a controlled release preparation should be considered for optimal pain management treatment. Timed or controlled release preparations (MS Contin, Kadian, Avinza, Oxycontin, Exalgo, Opana ER, Zohydro) are released over a 12-24 hour period and theoretically provide steady prolonged analgesia. They are generally considered in opioid tolerant patients when analgesia cannot be maintained with a reasonable number of daily short acting doses (4-6). Neither short or timed release opioids have been shown to be more effective or safer than the other.7 As with most drugs, a physician should start with a low dose and titrate up until the clinical objective (reasonable analgesia) is obtained or dose limiting ADE’s occur. An example of an escalating opioid treatment algorithm often used by the author, when acetaminophen and NSAID’s are either ineffective or contraindicated, begins with a trial of tramadol 50 mg TID. If benefit is appreciated but pain control still suboptimal after one month, the medication is increased over a period of months to a maximum of 100 mg QID. If tramadol is ineffective or contraindicated, hydrocodone would be the next step, using a dose of 5-10 mg with 325 mg acetaminophen preparation up to QID. If hydrocodone is insufficient after a several month trial, oxycodone at the same dose would be a logical step up. If a regimen of 10 mg hydrocodone or oxycodone QID trialed over a period of 2-3 months is sub therapeutic, then a timed release preparation would be considered. Treatment Outcome: Analgesia and patient functioning are monitored and used as measures of treatment success. The patient’s self-report of pain using the numerical rating scale (NRS), 0-10 on a 10 point scale, is a clinically simple measure to use despite its deficiencies. It is also important to measure the patient’s functional improvement with treatment. The patient’s activities of daily living (ADL’s), work, or family interactions that are facilitated by the current treatment are closely followed by the caregiver and there are several proprietary forms that can also be used. Side effects: Constipation is the most common and almost universal ADE with increasing opioid doses. Other side effects that should be explored are lethargy, mental clouding, disrupted sleep cycle, and sexual dysfunction. The latter is a common though underappreciated adverse effect of chronic opioids. Compliance: Compliance with dosing and aberrant drug taking behavior should be continuously monitored. Some red flags are: reports of missing or stolen drugs, requests for early refills, obtaining opioids from another physician, and an overriding concern about obtaining the medications instead of the analgesia the drug may provide. Several tools to assure compliance include pill counting, urinary drug testing (UDT), and the Florida Prescription Drug Monitoring (FLPDM) Report. However, no single measure is specifically required by law and there is no absolute standard of care on the frequency of such testing. The FLPDM, which any Florida licensed physician can access, is a particularly effective method to monitor duplicate prescribing from multiple sources for a single patient. DOA’s, non-prescribed narcotics, and not taking the prescribed opioid can be detected by UDT. Urinary testing every patient, every month, regardless of risk stratification, should not be considered standard of care.12 16
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A simple strategy to use at follow up evaluation is the “5 A’s: Analgesia, Adverse side effects, Activities of daily living, Affect, and Aberrant drug taking behavior.14 Medicolegal Concerns: Most states, including Florida, use the Federation of States Medical Boards Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain (MPUOA) as the basis of their statutes.15 MPUOA has also been adopted by the American Academy of Pain Medicine, the Drug Enforcement Administration, the American Pain Society, and the National Association of State Controlled Substances Authorities. MPUOA views pain management as an important area of patient care integral to the practice of medicine, that opioid analgesics may be necessary for the relief of certain pain conditions, and that physicians should not be sanctioned solely for prescribing opioid analgesics. However, prescribers must only prescribe opioids for legitimate medical purposes and will be held to a safe and best clinical practice. MPUOA makes clear what state medical boards will consider as inappropriate management of pain, and has adopted criteria for use in evaluating a physician’s management of a patient with pain (Table 3). __________________________________________________________________ Table 3: Adapted from the Federation of States Medical Boards Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain15 Inappropriate management of pain, and considered a departure from accepted best clinical practices, are: • Inadequate attention to initial assessment to determine if opioids are clinically indicated • Inadequate determination of risks • Inadequate monitoring during the use of potentially abusable medications • Unjustified dose escalation without adequate attention to risks or alternative treatments • Excessive reliance on opioids, particularly high dose opioids for chronic pain management • Not making use of available tools for risk mitigations (i.e., state prescription drug monitoring program) Criteria to be used in evaluating a physician when prescribing opioids for chronic pain: • Understanding Pain (physician must understand relevant pharmacology and clinical issues) • Patient Evaluation and Risk Stratification (prior to deciding to prescribe opioid therapy) • Development of a Treatment Plan and Goals (reasonable analgesia and improvement, improvement of function, and avoiding excess medications) • Informed Consent and Treatment Agreement • Initiating an Opioid Trial (defined period of time with specific endpoints) • Ongoing Monitoring and Adapting the Treatment Plan • Periodic Drug Testing (e.g., UDT’s, pill counting, or PDMP report) • Consultation and Referral (pain, addiction, mental health, or other specialist as needed) • Discontinuing Opioid Therapy (when risks outweigh benefits, clinical goals not obtained, ADE’s, misuse/diversion) • Medical Records • Compliance with Controlled Substance Laws and Regulations (DEA registration, state license) ___________________________________________________________________ CONTINUED ON PAGE 18
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Florida Statutes: Florida physicians prescribing opioids should be aware of several Florida Statutes.16 Probably the most important for non-pain management specialists is Statute 456.44, Controlled substance prescribing. Statute 456.44 mandates that a physician who prescribes controlled substances for the treatment of chronic nonmalignant pain must designate himself or herself as a controlled substance prescribing practitioner on the physician’s practitioner profile. In the Standard of Practice section of Statute 456.44, physician requirements are defined. A complete medical history and a physical examination must be conducted before beginning treatment. The medical record must document the nature and intensity of the pain, current and past treatments, coexisting diseases, the effect of the pain on physical and psychological function, a review of previous medical records, previous diagnostic studies, and history of alcohol and substance abuse. The record shall document the presence of a recognized medical indication for the use of a controlled substance. There must be a written plan for assessing each patient’s risk of aberrant drug-related behavior, which may include drug testing. Physicians must assess each patient’s risk for aberrant drug-related behavior and monitor that risk on an ongoing basis. The physician must develop a written treatment plan that states objectives to be used in determining treatment success, such as pain relief and psychosocial function. The physician shall use and maintain a written controlled substance agreement. The physician shall adjust drug therapy to the individual medical needs of each patient. Other treatment modalities, including a rehabilitation program, should be considered. Risks, including that of abuse and addiction, must be discussed. The patient shall be seen by the physician at regular intervals, not to exceed three months, to assess treatment efficacy, ensure the controlled substance remains indicated, evaluate progress toward treatment objectives, consider adverse drug effects, and review the etiology of the pain. The physician shall refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. Accurate, current, and complete records must be maintained. Patients with signs or symptoms of substance abuse shall be immediately referred to a board-certified pain management physician, an addiction medicine specialist, or a mental health addiction facility. Statute 456.44 specifically exempts from this subsection any board-eligible or boardcertified anesthesiologist, physiatrist, rheumatologist, or neurologist, or a board-certified physician who has surgical privileges at a hospital or ambulatory surgery center and primarily provides surgical services. This subsection does not apply to board-eligible or board-certified medical specialists who have completed an approved fellowship in pain medicine and perform interventional pain procedures of the type routinely billed using surgical codes.
nonmalignant pain. Each pain-management clinic must register with the department. Specific exemptions to the registration requirement for physicians are the same as those of Statute 456.44. The department shall deny registration to any clinic that is not fully owned by a physician, or to a physician whose application for a license to prescribe or administer a controlled substance has been denied or revoked, or who has been convicted of the receipt of illicit and diverted drugs. A physician, or physician extender, must perform a physical examination of a patient on the same day that a controlled substance is prescribed. If the physician prescribes more than a 72-hour dose of controlled substances for the treatment of chronic nonmalignant pain, the physician must document the reason in the patient’s record.
Chapter 893, Drug Abuse Prevention and Control16 contains Statute 893.055, Prescription drug monitoring program, which mandates that each time a controlled substance is dispensed to an individual, the controlled substance shall be reported to the department, and then to the electronic data base. Statute 893.11, Suspension, revocation, and reinstatement of business and professional licenses, considers that any physician convicted of the sale or trafficking in a controlled substance constitutes an immediate serious danger to the public health and safety, and is grounds for disciplinary action including immediate emergency suspension of an individual professional license.
8. Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother. 2013 Nov;13(11): 1201-20.
Chapter 58, Medical Practices, contains Statute 458.326, Intractable pain; authorized treatment, which defines “intractable pain” as pain for which the cause cannot be removed and otherwise treated, and authorizes that a physician may prescribe or administer any controlled substance to a person for the treatment of intractable pain, provided the physician does so in accordance with that level of care, skill, and treatment recognized by a reasonably prudent physician under similar conditions and circumstances. Statute 458.3265, Pain-management clinics, defines a pain management clinic as any publically or privately owned facility that advertises any type of painmanagement services; or where a majority of patients are prescribed opioids, benzodiazepines, barbiturates, or carisoprodol for the treatment of chronic 18
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Conclusion: Opioids are an integral component of acute and chronic pain management, and can be used, with modest benefit, for chronic non-malignant pain. Excessive and inappropriate opioid prescribing led to a major epidemic in prescription drug abuse and preventable mortality, necessitating the state to make appropriate statutory changes. Opioids can be used if the practice is consistent with current medical standard of care and FL Statues. Knowledge of both is required in order to practice due diligence in preventing abuse and diversion. ___________________________________________________________________ References: 1. Centers for Disease Control and Prevention (CDC). Vital Signs: Overdoses of prescription opioid pain relievers-United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011 Nov 4;60(43):1487-92. 2. Estep B, Hjalmarson, Abdullah H. OxyContin abuse spreads from Appalachia across U.S. [Internet]. Washington: McClatchy Newspapers; 2011 Mar 13 [cited 2016 March 15]. Available from: http://www.mcclatchydc.com/news/crime/article24616228.html 3. Warner M, Chen L, Makuc D. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS Data Brief, No. 22. Hyattsville (MD): National Center for Health Statistics; Sep 2009. 4. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of national findings. Rockville (MD): Office of Applied Studies, NSDUH; 2010 Sept. Report No.: Series H-38A, HHS Publication No. SMA 10-4586Findings. 5. Goldberger B, Thogmartin J, Johnson H, et al. Drug Overdose Deaths --- Florida, 2003—2009. MMWR. 2011 Jul 8;60(26):869-72. 6. Noble, M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006605. 7. Argoff CE, Silvershein DI. A comparison of long- and short-acting opioids for the treatment of chronic noncancer pain: Tailoring therapy to meet patient needs. Mayo Clin Proc. 2009 Jul;84(7):602-12.
9. Furlan AD, Reardon R, Weppler C, National Opioid Use Guideline Group. Opioids for chronic noncancer pain: A new Canadian Practice Guideline. CMAJ. 2010 Jun 15;182(9):923-30. 10. Chou R. 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: What are the key messages for clinical practice? Pol Arch Med Wewn. 2009 Jul-Aug;119(7-8):469-77. 11. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in paid medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-12. 12. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. 2016 Mar 18;65(1):1-49. 13. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005 Nov-Dec;6(6):432-42. 14. Pain Management Network. 5 A’s- Opioid therapy monitoring tool [Internet]. [cited 2016 March 15]. Available from: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/212761/5_ As_of_Analgesia.pdf15. Federation of State Medical Boards. Model policy on the use of opioid analgesics in the treatment of chronic pain [Internet]. 2013 Jul [cited 2016 March 15]. Available from: http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/pain_policy_july2013.pdf 16. 2016 Florida Statutes, Florida Legislature. Available from: http://www.leg.state.fl.us/statutes/ index.cfm?App_mode=Display_Statute&URL=0800-0899/0893/0893.html
Reprinted with permission from the Duval County Medical Society (DCMS)
CME OPPORTUNITY
CME POSTTEST: Responsible Opioid Prescribing Circle one answer. $55.00 charge for non-DCMS members*. (Return by mail to 1301 Riverplace Blvd., Suite 1638, Jacksonville, FL 32207) 1. Which of the following is not true regarding opioids form 2000-2010? a. Opioid overdose death rates, sales, and substance abuse treatment admissions increased in parallel. b. The incidence of death secondary to overdose of opioids increased yearly. c. The increased incidence of drug overdose death rate was mostly due to non- prescription drugs of abuse. d. In Florida, the overall opioid overdose death rate was significantly above the national rate. 2. Regarding opioids: a. Therapeutic benefit is mediated primarily via mu opioid receptors. b. Cochrane Review concluded that there is strong evidence that long-term opioid therapy for non-malignant pain can provide significant pain relief. c. Cochrane Review concluded that there is moderate evidence that long-term opioid therapy for non-malignant pain improves quality of life and functioning. d. Generally, opioids provide better relief of chronic than acute pain. 3. Adverse drug effects of opioids typically include: a. Hypertension and tachypnea b. Generalized hyperarousal state c. Constipation d. Polyuria e. Improved sexual performance 4. Medical standards of care in opioid prescribing: a. Differ significantly from standards of care of other medical treatment. b. Differ from other medical standards in not requiring a physical examination. c. Require either urinary drug testing or pill counting every visit. d. Require a history, risk assessment, regular follow-up and monitoring. 5. In assessing risk for opioid abuse and/or diversion, which of the following is not a risk factor? a. Psychiatric illness b. History of childhood sexual abuse c. Age 46-55 d. Personal history of alcohol or prescription drug abuse e. Family history of alcohol or prescription drug abuse 6. In assessing treatment outcomes when using chronic opioid therapy, a. Level of pain control by patient’s self-report is the only concern. b. Forms must be filled out by patient stating level of pain on 10 point scale. c. A practical strategy which can be used clinically is asking the patient about the 5 “b’s.” d. Level of functioning is as important as pain control. 7. In attempting to assure compliance with chronic opioid therapy, Florida physicians are required to: a. Follow up with the patient monthly. b. Perform a urinary drug test at least every three months. c. See the patient at regular intervals to assess treatment efficacy and ensure controlled substance treatment remains indicated. d. Discharge the patient within 30 days of breaking the opioid agreement.
8. Which of the following is not mandated by Statute 456.44, Controlled substance prescribing? a. A physician who prescribes controlled substances for the treatment of chronic nonmalignant pain must designate himself as a controlled substance prescribing practitioner. b. Physician must perform monthly urinary drug testing. c. A complete medical history and a physical examination must be conducted before beginning treatment. d. The physician shall use and maintain a written controlled substance agreement. What will you do differently as a result of this information? _______ ________________________________________________________ ________________________________________________________ ________________________________________________________ How will you apply what you learned to your practice? ___________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Evaluation Questions & CME Credit Information Please evaluate this article in the following areas. Choose one number using this scale: 1= Strongly Agree to 5= Strongly Disagree The article met the stated objectives: 1 2 3 4 5 The articles were appropriate to my practice: 1 2 3 4 5 The topics were current and well presented: 1 2 3 4 5 Comments: ______________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Name (Print) _____________________________________________ Email ___________________________________________________ Address/City/State/Zip ____________________________________ ________________________________________________________ Phone _______________________ Fax _______________________ DCMS Member (circle) YES NO *Non-Member Charge ($55.00) – See payment options below Check: Make check payable to Duval County Medical Society. Credit card: Visa MasterCard
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Avon Doll, M.D. Nephrology North Florida Nephrology Associates Married to Louie Doll Oral Roberts University
David Stewart, M.D. Pathology Pathology Associates Married to Gillian Stewart University of New Mexico
Nancy Loeffler, M.D. Secretary Anesthesiology Anesthesiology Associates of Tallahassee Married to Duane Pickel Baylor College of Medicine
Terreze Gamble, M.D. Family Medicine Tallahassee Primary Care Associates Married to Vaughn Samuel American University of the Caribbean
Jay Walton, D.D.S. Dentistry Married to Susan Walton Emory University
Kenneth R. Wasson, M.D. Treasurer Pulmonary Medicine Retired Married to Lee Wasson Vanderbilt University
Tracey Hellgren, M.D. CMS President Family Medicine Patients First University of Florida
Barbara Williams, M.D. Family Medicine Patients First Married to Dennis Williams, M.D. University of Florida
Joedrecka Brown-Speights, M.D. Family Medicine FSU College of Medicine Married to Gregory Speights Emory University
David Jones, M.D. Pediatrics Capital Health Plan Married to Dottie Jones Ohio State University
Charles Williams, M.D. Radiology Radiology Associates Married to Pat Williams Medical College of Georgia
Walt Colón, D.M.D. Dentistry Married to Marybeth Colón University of Kentucky
Fred Lindsey, M.D., Emeritus Radiology Retired Married to Jimmie Lindsey Medical College of Georgia
Pam Irwin Executive Director, Capital Medical Society
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CMS FOUNDATION
The Impact of Private Support: Capital Medical Society Foundation’s community of donors strategically help fulfill its mission “to support the charitable efforts of physicians and others, increase access to healthcare, promote education and serve the community’s health needs through innovative projects that are exemplary, affordable and dignified.”
DONATE TO THE CMS FOUNDATION
WE THANK OUR DONORS We thank the following people/organizations who made a donation to the CMS Foundation this past month: For CMS Foundation James Patty, M.D. For Scholarship Fund Efren Baltazar, M.D. For We Care Network Rosalie Carlin – In Honor of Rev. Margaret Doherty and William Phelan, PA-C Lenox Family Partnership For We Care Network Endowment Anonymous For Year-End Appeal – Scholarship Fund C. Raymond Cottrell, M.D. David Miles, M.D. For Year-End Appeal – We Care Network Capital City Anesthesia, LLC Wilford and Mildred Dorsey Nancy Loeffler, M.D.
Your gifts to Capital Medical Society Foundation transform lives in the Big Bend.
• Access to healthcare is increased through gifts to We Care Network and the We Care Network Endowment Fund. More than $79 million in donated specialty medical and dental care has been provided to low income, uninsured patients since the program was created in 1992. In fiscal year 2015-16, which ended June 30, 2016, more than $7 million in health care was donated. Gifts support the salaries and benefits of the case management team who coordinate donated care. • To provide incentives to keep medical students trained at FSU College of Medicine in the Big Bend after completion of their residencies and help meet the growing demand for physicians in Florida, gifts to the Scholarship Fund provide scholarships to FSU College of Medicine students who have expressed an interest in returning to the Big Bend to practice after completion of their residencies. $47,000 was distributed to eight medical students in 2016. • Gifts to Capital Medical Society Foundation help provide operation resources for Capital Medical Society Foundation. In 2015-16, funds were used for a roof repair, purchase of a computer firewall upgrade, rental unit maintenance, exterior painting, and office renovations to accommodate additional staff. In addition, modest grants to area non-profits whose programs improve access to health care for the underserved. In 2016, CMSF awarded $10,000 in grants to Elder Care for their In-Home Services Program and to Lighthouse of the Big Bend to provide tools to the visually impaired to improve their access to health care. Gifts to Honor and In Memoriam: You can make a donation to the CMS Foundation in memory of someone who has passed away or in honor of someone, such as a fellow physician, you hold in high esteem or has taken care of you or your family. CMS Foundation will send an acknowledgement letter to those you memorialize and honor. How to Give: Through the generosity of donors, funds have been created in order to establish financial stability to meet our mission. You can donate at any time to one of CMS Foundation’s current funds: 1) Capital Medical Society Foundation-area of greatest need 2) The Capital Medical Society Foundation Endowment 3) We Care Network 4) We Care Network Endowment 5) Scholarship Fund 6) The Ronald G. Pickett Endowment Checks should be made payable to the CMS Foundation and indicate on the memo line of your check to which designation you would like to donate. Bring your check to the CMS Office or mail it: Capital Medical Society ~ 1204 Miccosukee Road ~ Tallahassee, FL 32308. If you would like to discuss a gift of appreciated securities, an insurance policy, designation of retirement plan assets, estate gift, or multi-year pledge, please contact: Pam Irwin, Executive Director pirwin@capmed.org or (850) 877-9018
22 CAP SCAN - A CAPITAL MEDICAL SOCIETY PUBLICATION
CMS FOUNDATION: WE CARE NETWORK
Praful Patel, M.D. Timothy Paulk, M.D. Michael Pentaleri, M.D. J. Daniell Rackley, M.D. Laurence Rosenberg, M.D. FOUNDATION
We Care Network
THANK YOU To our CMS members and We Care partners who saw new patients for the We Care Network in December 2016. Your generosity and support of the We Care Network makes a difference. Physicians Marie Amanze, M.D. Arvind Bakhru, M.D. David Bellamy, M.D. Tim Broeseker, M.D. Acquinonette Bryant, M.D. J. Brewster Caldwell, D.O. Michael Cavallaro, M.D. George Cohen, M.D. Raymond Cottrell, M.D. Chris DeRosier, M.D. David Dolson, M.D. Jerry Ford, M.D. Alexander Franz, M.D. Akash Ghai, M.D. Jerry Harris, M.D. Muhanad Hasan, M.D. Dwight Hooper, M.D. James Hunt, D.O. Iman Imanirad, M.D. Marc Inglese, M.D. Ken Kato, M.D. Farhat Khairallah, M.D. Sayeed Khalillullah, M.D. Ben Kirbo, M.D. Hari Kolli, M.D. Maribel Lockwood, M.D. Kurt Luhmann, M.D. John Mahoney, M.D. Michael Mangan, M.D. Ovidiu Marina, M.D. Jonathan Melquist, M.D.
Tim Ruark, M.D. Stephen Sgan, M.D. Hardeep Singh, M.D. David Smith, M.D. Joshua Somerset, M.D. Joseph Soto, M.D. Anthony Wright, M.D. Richard Zorn, M.D. Dentists Eric Amundson, D.D.S. William Baldock, D.D.S. Joseph Barnett, D.M.D.
The We Care Network strongly encourages our volunteer physicians and dentists to send their value of donated services to us. The value of donated services is important for us to share with our funders and the community. Also, up to five hours per biennium of CE Credit may be fulfilled by performing pro bono medical and dental services to We Care Network patients, if we have received documentation of value of services. You can send your value of donated services via fax to Rosemary Evans at (850) 201-0085 or mail to 1204 Miccosukee Road, Tallahassee, FL, 32308. Thank you! Please contact Rosemary Evans at revans@capmed.org or 201-0130 if you are a We Care volunteer and you provided volunteer specialty care in the month of December 2016 and your name was omitted.
We thank our referring providers from December 2016: Eboni Allen, ARNP
Rodolfo Oviedo, M.D.
Jonna Bradley, ARNP
Richard Palmer, M.D.
Daniel Breivogel, ARNP
Kyara Paulk, ARNP
James Sykes, D.M.D.
Lysmar Carrion-Dinguis, M.D.
Lisa Perkins, M.D.
Facilities
Susan Dunbar, ARNP
Gloria Ramos, M.D.
Mignon Emenike, M.D.
Charlie Richardson, M.D.
Shirley English, ARNP
Laurence Rosenberg, M.D.
Cynthia Evans, ARNP
Lucilita Salvador, ARNP
Sharron Foster, M.D.
Roy Schwartz, M.D.
Anneka Gaffney, ARNP
Thomas Serio, M.D.
Judy Griffin, ARNP
Alanna Steaple, ARNP
Hantz Hercule, M.D.
Christopher Sundstrom, M.D.
Howard Kessler, M.D.
Tallahassee VA Health Care
Brian Beck, D.M.D. Walter Colón, D.M.D. William McFatter, D.D.S. Lawrence Pijut, D.M.D.
Affordable Dentures Anesthesiology Associates Beachton Denture Clinic Capital Regional Medical Center Desloge Home Oxygen Leon County Dental Clinic Neighborhood Medical Center Dental Clinics Pathology Associates Radiology Associates Seven Hills Surgery Center Smile Connection at Bond Community Health Center Southeastern Surgery Center Tallahassee Diagnostic Imaging Tallahassee Endoscopy Center Tallahassee Memorial HealthCare
Elaine Larkins, ARNP
Center
Esaias Lee, M.D.
Leonard Tolley, D.D.S.
Ashok Manocha, B.D.S.
Jeffrey Wasserman, D.O.
Marcia Morris, ARNP
Franklin Watson, D.D.S.
Tallahassee Outpatient Surgery Center TMH Family Medicine Residency Program Women’s Imaging Center
Rodolfo Oviedo, M.D. Kaushal Patel, M.D.
John Ness, M.D. Rose Origa, ARNP
DURING THE MONTH OF DECEMBER, THE WE CARE NETWORK: RECEIVED 163 REFERRALS, WITH 106 PATIENTS NEW TO THE PROGRAM
SCHEDULED 96 APPOINTMENTS WITH VOLUNTEER PHYSICIANS AND DENTISTS
$125,268 IN DONATED CARE WAS REPORTED BY WE CARE VOLUNTEERS
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