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Inside this issue of
VOLUME 63, NUMBER 1 Addiction Medicine Spring 2012 EDITOR IN CHIEF Raed Assar, MD (Chair) MANAGING EDITOR Leora Legacy ASSOCIATE EDITORS Abubakr Bajwa, MD Steven Cuffe, MD Ruple Galani, MD Kathy Harris (Alliance) Sunil Joshi, MD (Vice Chair) James Joyce, MD Daniel Kantor, MD Neel Karnani, MD Mobeen Rathore, MD James St. George, MD
Executive Vice President Bryan Campbell DCMS FOUNDATION BOARD OF DIRECTORS Benjamin Moore, MD, President Todd L. Sack, MD, Vice President Kay M. Mitchell, MD, Secretary J. Eugene Glenn, MD, Treasurer Guy I. Benrubi, MD, Immediate Past President Bouli Amoli, MD, Resident Raed Assar, MD Ashley Booth Norse, MD Elizabeth Burns, MD J. Bracken Burns, DO Kelli Deese, MD, Resident Malcolm T. Foster, Jr., MD Ruple Galani, MD Jeffrey M. Harris, MD LCDR James Hodges, MC, USN, Resident Mark L. Hudak, MD TraChella Johnson, MD Sunil N. Joshi, MD James Joyce, MD Daniel Kantor, MD Neel G. Karnani, MD Harry M. Koslowski, MD Eli N. Lerner, MD Stephen Mandia, MD Jesse P. McRae, MD Jason D. Meier, MD Nitesh N. Paryani, MD, Resident Nathan P. Newman, MD Mobeen H. Rathore, MD Sanjay Swami, MD David L. Wood, MD Northeast Florida Medicine is published by the DCMS Foundation, Jacksonville, Florida, on behalf of the County Medical Societies of Duval, Clay, Nassau, Putnam, and St. Johns. Except for official announcements from the County Medical Societies, no material or advertisements published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies. All advertising is subject to acceptance by the Editor in Chief. Address correspondence and advertising to: 555 Bishopgate Lane, Jacksonville, FL 32204 (904-355-6561), or email: email@example.com. COVER: "Breaking the Addiction Chain". Concept developed by Ms. Marigrace Doran, DCMS Webmaster.
www . DCMS online . org
Northeast Florida Medicine
Addiction: None are Immune
Addiction for the Non-Behavioral Health Physician: Identification and Office-Based Strategies for Management
Raymond M. Pomm, MD, Guest Editor
Raymond M. Pomm, MD
Addiction Treatment Under Managed Care
The Physician's Approach to Substance Use in Adolescents
Methadone Treatment in Pregnancy...That Can't Be Right, Can It?
Jason Jerry, MD and Gregory B. Collins, MD
Jason B. Fields, MD and Scott A. Teitelbaum, MD
Stacy Seikel, MD
Nonpharmacologic Strategies for Treating the Addicted Patient in an Office-Based Setting: Motivational Interviewing
Heidi A. Pomm, PhD
Leadership Beyond the Exam Room
DCMS EVP Introduction - Bryan Campbell
Daniel Kantor, MD, Young Leadership Award Recipient
Insert Domestic Violence Update (CME)
Nancy Motherway, LCSW; Margaret Ghee, LMHC and Raymond M. Pomm, MD
42-44 DCMS Annual Meeting
From the Editor’s Desk From the President’s Desk DCMS History Book Order Form Residents' Corner Trends in Public Health
5 10 11 37
Northeast Florida Medicine Vol. 63, No. 1 2012 3
From the Editor’s Desk
Addiction Management in Mainstream Medicine Addiction can erode health, financial resources, the quality of interpersonal relationships, and lead to chronic anxiety and depression. Addictive prone behaviors are those with the capacity to create pleasure while at the same time reduce discomfort associated with stress or other negative emotions. This definition expands the scope of addiction to not only substance and drug abuse but also other behaviors and obsessions. Are we, as physicians, prepared to identify addictions and manage these conditions effectively? People attempt to manage their lives during all stages of growth, whether happy or sad. The media depicts alcohol and drugs as plausible options for both celebrating and self-medicating. For some, they become the preferred activity and eventually develop into full fledged dependence and addiction. Substance and drug abuse related health care costs and their burden on society are tremendous. Furthermore, the overall health care cost of behavioral addictions is not known. The health problems that behavioral addictions create are just as likely to bring a person to a physician as substance or drug abuse. For example, food addiction or overeating is a well established cause of obesity, which leads to life threatening and disabling co-morbid conditions. When people manage stress, they might surf the Internet, play computer games, gamble, or shop, which are sedentary activities. Long hours of sitting and lack of exercise contributes to obesity, musculoskeletal, and circulatory problems. On the opposite end of the spectrum, the person addicted to exercise may also develop a variety of musculoskeletal issues. Additionally, sex addicts are at higher risk for sexually transmitted diseases and HIV. How does our healthcare system deal with such issues? Office visits provide the overwhelming majority of patient-physician interactions. During these visits, patients fill out questionnaires, staff asks about reasons for visits, and physicians inquire about complaints and issues. These office visits are generally structured for efficient throughput. How likely is this to uncover a substance abuse issue or a behavioral addiction? If such issues are identified, how likely is the physician to manage them effectively? Raed Assar, MD, MBA Editor-in-Chief Northeast Florida Medicine
Based on a national survey by Columbia University in 2000 (available at: http://bit.ly/xvJrCO), less than 20% of primary care physicians considered themselves very prepared to identify alcohol or drug dependence. A majority of physicians (57.7%) say they don’t discuss substance abuse with their patients because they believe their patients lie about it, and nearly 85% of patients agree.
I recently reviewed the book titled, Management of the Addicted Patient in Primary Care. (Pomm HA, Pomm RM. Management of the addicted patient in primary care. New York: Springer Publishing; 2004) It was co-authored by this issue’s Guest Editor, Raymond Pomm, MD, and his wife, Heidi Allespach Pomm, PHD, who also contributed in this issue. The first sentence captured my attention. It highlights the struggle of many physicians to accept that addiction is a disease. The book further illustrates that the American Medical Association labeled Alcoholism a disease back in 1966. However, people’s ability to choose clouds the logic. Experts now agree that willpower alone is not enough to stop addiction once it manifests. Addicted patients require sophisticated and rigorous programs in addition to the personal desire to do something because their lives became unmanageable. This unclear understanding regarding the issue of self-control may contribute to potential underlying prejudice. It may result in frustration and anger when confronted with an individual suffering from substance, drug, or behavioral addictions. In summary, many barriers work together to prevent appropriate identification, intervention, and treatment planning. Without established methods, does the busy schedule of a physician, coupled with the pressure to keep the patient satisfied, allow for the best environment to explore patients’ psychological wellbeing and counseling needs? The answer is likely, no. Substance or drug abuse and behavioral addictions are likely to remain a significant health care issue. Early in my medical training I realized patients seek not only medical management, but also psychological and emotional help. Recently, Dr. Thomas Peters, past DCMS President (2002), described this notion eloquently to me as, “Patients need a physician with whom they can talk.” Developing practices, tuned into and open to addiction issues, requires specific tools and systematic approaches. The “Just Say No” approach is clearly not the silver bullet for addiction once established. The authors in this issue efficiently and skillfully present the latest information on such tools and approaches for the physicians to consider in their practices. For the betterment of our society, I hope this issue on addiction helps our medical community become more prepared and effective in identifying and managing the issue of addiction.
4 Vol. 63, No. 1 2012 Northeast Florida Medicine
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From the President’s Desk
We Live in Interesting Times When I was inaugurated December 1, 2011 as the 125th DCMS President, I was proud to stand before my colleagues and take the Oath of Office from my husband, Ronald Norse. However, I realize much trust and confidence has been placed in me by all of you, and that is quite humbling. I take this position very seriously and will dedicate my time and energy to serving you- its members. I promise to do everything in my power to live up to your expectations as well as the legacy of those who have held the position before me of the Society’s 159 years. I am especially honored to be the third female DCMS President and to join the exclusive ranks of the previous female presidents; Dr. Kay Gilmour (1992) and Dr. Kay Mitchell (2003). There is an ancient Chinese curse that states: “May you live in interesting times.” Well these are definitely interesting times. U.S. medicine is at a crossroads. According to the government’s annual health report, Americans’ life expectancy is 78.2 years, an all time high. Yet, if you read the headlines, you get the impression that our American health care system has been a failure when compared to the rest of the world. Why is this? Because technology and the people that know how to implement it cost money. Make no mistake; the current war on the medical system in the U.S. is about cost, not about the quality of care we as physicians provide. When President Obama signed “The Patient Protection and Affordable Care Act” into law in March 2010, he set into motion sweeping changes to our healthcare delivery system. Understanding how this far reaching legislation will impact and redefine the practice of medicine is critical, but keep in mind the basis for all the change is cost containment and as physicians we are about to enter an era of cost containment that makes the previous two decades seem tame in comparison. Florida is cutting health care benefits because it doesn’t have the money to pay for Medicaid. We know that the cost reductions projected from Medicare will be more difficult to realize than Congress thought. Our challenge as physicians will be the struggle to maintain quality in a cost containment era. New payment models are on the horizon such as accountable care organizations, bundled payment models, and value-based payment models based upon both outcomes and utilization. What does this mean for organized medicine? In the last year we have seen a trend towards more employed physicians in Florida and nationally. In March 2011 a New England Journal of Medicine article titled “Hospitals’ Race to Employ Physicians — The Logic Behind a MoneyLosing Proposition” reports, “U.S. hospitals have begun responding to the implementation of health care reform by accelerating their hiring of physicians. More than half of practicing U.S. physicians are now employed by hospitals or integrated delivery systems, a trend fueled by the intended creation of accountable care organizations (ACOs) and the prospect of more risk-based payment approaches. Employment decisions made by physicians today will have long-term repercussions on the practice of medicine…and the viability of our medical societies as well as medical societies across the US.” Ashley Booth Norse, MD 2012 DCMS President
Like all membership organizations, DCMS is struggling to increase member numbers. DCMS has seen a continuous decline in membership over the last several years, and this is discouraging because members are the Society’s cornerstone. In order to strengthen the DCMS, we have to improve membership retention and recruitment. We can’t let this current downward trend continue. The demographics of medicine have changed and so have the needs of members. DCMS has to reassess what its members want from the Society and also learn to better communicate with them. In the coming year I plan to reassess members’ needs to ensure that we are providing the necessary services and resources to them and ultimately improve our membership numbers. As some of you already know, the DCMS Foundation Board of Directors has decided to sell the current Bishopgate Lane building and property, which has been the home site of DCMS since 1986. This is a historic milestone that emphasizes DCMS is much more than bricks and mortar. It is the people that devote their time and talents that make this a viable organization. The sale and eventual move will be a huge undertaking, but it is necessary to keep DCMS progressive. Yes, medicine in America is at a crossroads and crossroads are challenging. However, it is the challenges, that while daunting, allow us to evolve and thrive. Medicine is still a very noble profession, and I encourage you to not be frustrated by all the rhetoric in Washington and Congress’ unwillingness to do what’s right by enacting meaningful tort, fixing the SGR and much more. Let it simply motivate us all to work even harder to provide an environment that removes distractions from the most important element of medical practice, the patient-physician relationship. I look forward to the upcoming year and I invite all of you to send me your input and suggestions as DCMS carefully chooses it path in 2012. (Ashley.Booth@jax.ufl.edu) www . DCMS online . org
Northeast Florida Medicine Vol. 63, No. 1 2012 5
Ashley Booth Norse, MD 125th President of the Duval County Medical Society
Ashley Booth Norse, MD, serves as an Assistant Professor of Emergency Medicine and Associate Director of the Emergency Medicine Residency Program at the University of Florida College of Medicine–Jacksonville.
“Leadership and learning
are indispensable to each other.” John F. Kennedy
6 Vol. 63, No. 1 2012 Northeast Florida Medicine
www . DCMS online . org
Presented by: north Florida CardiovasCular eduCation Foundation Co-sPonsored by: ameriCan College oF Cardiology Foundation Florida ChaPter, ameriCan College oF Cardiology
M a r r i ot t S awg r a S S h ot e l Ponte Vedra Beach, Florida
Save the Date! Saturday, april 14, 2012
AmericAn college of cArdiology FoundAtion
A Cardiovascular Education Opportunity Guest Faculty includes: William T. Abraham, MD, FACC Louis J. Aronne, MD, FACC Peter C. Block, MD, FACC Alan S. Brown, MD, FACC Robert A. Guyton, MD, FACC Paul J. Hauptman, MD, FACC Alan S. Maisel, MD, FACC Barbara H. Roberts, MD, FACC Philip R. Schauer, MD, FACS
Symposium includes dinner presentation by
dr. John g. harold, Md, Macc, MacP, FccP, Faha
For more information and to register visit www.pvcardiacsymposium.com
Registration and Breakfast Welcome
SYMPOSIUM SCHEDULE - SATURDAY, APRIL 14, 2012 7:00 AM – 8:15 AM 8:15 AM – 8:30 AM
MANAGEMENT OF OBESITY Introduction of Speakers and Case Presentation Louis Aronne, MD The Emerging Role of the Physician in Obesity Treatment Philip Schauer, MD Bariatric Surgery – Most Effective Therapy for Severe Obesity and Cardiovascular Risk Reduction Panel Discussion BREAK CONGESTIVE HEART FAILURE Introduction of Speakers and Case Presentation Paul Hauptman, MD Advanced Heart Failure in the Elderly William Abraham, MD Devices for Monitoring and Managing Heart Failure Panel Discussion LUNCH AND PRESENTATION Barbara Roberts, MD Gender-Specific Aspects of Cardiovascular Disease
8:30 AM 8:40 AM 9:10 AM 9:40 AM 10:00 AM 10:30 AM 10:40 AM 11:10 AM 11:40 AM 12:15 PM
PRACTICAL CLINICAL CARDIOLOGY Introduction of Speakers and Case Presentation Alan Brown, MD Advanced Lipid Testing and Therapy Alan Maisel, MD Biomarkers in Cardiovascular Syndromes Panel Discussion BREAK VALVULAR HEART DISEASE Introduction of Speakers and Case Presentation Robert Guyton, MD Innovations in Surgical Mgmt. of Valvular Heart Disease Peter Block, MD Transcatheter Aortic Valve Replacement: Choosing Patients for Commercial Valve Versus Ongoing Trials Panel Discussion RECEPTION AND DINNER John Harold, MD Atherosclerosis in Ancient Humans: Results of the Horus Study of Ancient Egyptian Mummies www . DCMS online . org
1:30 PM 1:40 PM 2:10 PM 2:40 PM 3:00 PM 3:30 PM 3:40 PM 4:10 PM 4:40 PM 5:00 – 7:30 PM
Northeast Florida Medicine Vol. 63, No. 1 2012 7
Guest Editorial: Leadership Award Recipient
Leadership Beyond the Exam Room Daniel Kantor, MD 2011 Philip H. Gilbert Young Physician Leadership Award Recipient Every physician is a leader. Physicians help navigate their patients through difficult health situations. All physicians are bound by the Hippocratic Oath to embrace and take on this form of leadership. There are, however, other forms of leadership besides diagnosing medical conditions and prescribing treatment. Those of us actively involved in organized medicine have a responsibility to nurture such leadership in ourselves, our peers and even our patients. While partnering with and leading our patients to greater opportunities for health is of itself the noblest of pursuits, we should not minimize other avenues to help those around us. As the national debate on Health Insurance Reform rages on, physicians have a responsibility, and an opportunity, to publicly explore true Health Reform. In our dizzying world of acronyms, such as PPACA and ACOs (Accountable Care Organizations), other forms of accountability are overlooked. We physicians should continue to educate our patients on their health needs, and to inform them of ways to become better guardians of their own health. Furthermore, insurers should be held accountable for adverse outcomes that stem directly from their attempts to deny care unreasonably. While there is a genuine place for prescription medication formularies and safety oriented prior authorization procedures, medical imaging has quickly become a sophisticated extension of the time-honored physical exam. Even when
insurers control their own costs of prescription medications, these external parties should not dictate how we examine our patients or which medical tools we use. Practice guidelines should be used as practice educational guidelines, as opposed to ways of restricting our knowledge in how to care for our patients. Too often, checkboxes and numbers (coding) are preferred over the hard-earned knowledge of excellent physicians. Patients do not always fall into neat boxes and categories, and it is unconscionable for these orphaned patients to be abandoned and not afforded the same benefits of modern medicine simply because their malady does not meet a current checklist of approved diagnoses. Too often, excellent clinicians confine themselves to the daily needs of their individual patients, but we should not abrogate our responsibility to help society develop more reasoned strategies to improving overall health. Physician involvement in medical associations such as the Duval County Medical Society (DCMS) is important in our efforts to influence the environment in which patient care is given. DCMS gives its members tools and resources to become leaders in their chosen profession. I am grateful to my mentors at DCMS for the guidance that they have given me in pursuing novel ways to improve patient care. Advocacy is the natural and necessary extension of the doctor-patient relationship. DCMS helps members learn how to stand-up for their patients and for the survival of medicine.
Daniel Kantor, MD, received the 2011 Philip H. Gilbert Young Physician Leadership Award at the DCMS Annual Meeting, December 1, 2011. This award, created to honor the memory and service of Philip H. Gilbert who served as DCMS Executive Vice President from 1984 until his death in 2004, recognizes young physicians with leadership traits that Mr. Gilbert would have admired. Candidates must meet the following eligibility criteria: Be a young physician from Northeast Florida, under 40 years of age or within the first eight years of professional practice after residency and fellowship training, as defined by the AMA; be active in the DCMS or other organized medicine service; be active in civic services; have medical staff (or similar) leadership experience; and be a strong advocate for medicine. Photos: (Top, bottom - L to R) Dr. Kantor receiving his award from Dr. Malcolm T. Foster, Jr., now DCMS Immediate Past President. Dr. Kantor and Philip Gilbert. (The pencil sketch of Mr. Gilbert was drawn by Alexander Braddock.)
See DCMS Annual Meeting article and photographs, pp.42-44 8 Vol. 63, No. 1 2012 Northeast Florida Medicine
www . DCMS online . org
Introducing New DCMS Executive Vice President
Bryan Campbell Becomes Fourth DCMS EVP DCMS President Ashley Booth Norse, MD, announced to the DCMS membership on January 23, 2012 that Mr. Bryan Campbell has been named as the next DCMS Executive Vice President. Mr. Campbell is only the fourth EVP in DCMS history, following Ernie Currie, Philip Gilbert and Jay Millson. (Now the EVP of the Florida Academy of Family Physicians) After a nationwide search and interview process, Mr. Campbell was selected as the new EVP. Prior to coming to DCMS on February 6, he was Director of Public, Media and Industry Relations at the American Association of Clinical Endocrinologists (AACE). His strong experience in working with the media, establishing relations with industry and corporations plus having a background in grass roots government relations make him well suited to lead DCMS forward in these critical times. DCMS President Dr. Booth Norse said, "We are very excited that Mr. Campbell has accepted the position of EVP for the DCMS and look forward to the coming year. Mr. Campbell brings national specialty society experience with him to DCMS but also a long background in communications and public relations which will be a tremendous asset to DCMS as we address member benefits and membership communication needs." Mr. Campbell, or Bryan, as most at DCMS call him, has strength and background in areas that will benefit the Society. These include working with media to increase coverage of DCMS events and initiatives, developing patient awareness campaigns about various medical conditions, establishing strategic partnerships with industry and professional groups, creating revenuegenerating programs to benefit DCMS, and managing grass roots legislative efforts. Bryan Campbell DCMS Executive Vice President
“I am honored to be following in the footsteps of such an accomplished EVP, Jay Millson,” said Campbell. “I hope to continue the organizational excellence he has established, while working hard to preserve and protect DCMS and the ability of its members to practice medicine.”
He added, " Because of the excellent leadership of Jay Millson and DCMS presidents, this organization is in great shape. I’m not being asked to come in and fix years of problems, but rather to help maintain the Society's success while using my expertise in media communications and partnership development to enhance DCMS efforts." Before his years in organized medicine, Bryan was a television executive at WTLV/WJXX in Jacksonville and in Eugene, Oregon, a campaign manager for a Clay County candidate. A resident of Orange Park, Bryan and his wife, Sarah, (Town Clerk of Orange Park) have two children: Lauren (14) and Nathan (12). Bryan enjoys singing and playing the guitar. Although not an Iron Man, he says, “I occasionally run road races, but not very fast.” Although Bryan was not hired to run marathons, he did “hit the road” running once he became EVP. He has been busy meeting DCMS members at events, board and committee meetings, and one-on-one. (Email at firstname.lastname@example.org if you need to contact him.) He has also been reaching out to the media and the community. The Society’s schedule is a full one and Bryan’s calendar has been filled with commitments since coming onboard. Welcome, Bryan!
Key 2012 DCMS Events April 15-17 - AMA Leadership Visit (DCMS Leadership Dinner April 16/see p. 39) Late Spring - Publication of DCMS History book, "Florida’s Pioneer Medical Society: A History of Duval County Medical Society and Medicine in Northeast Florida" (see p.10)
www . DCMS online . org
Northeast Florida Medicine Vol. 63, No. 1 2012 9
Florida’s Pioneer Medical Society
A History of Duval County Medical Society and Medicine in Northeast Florida Authored by: Leora Legacy
After two years of research and writing, the Duval County Medical Society (DCMS) announces the release of Florida’s Pioneer Medical Society: A History of Duval County Medical Society and Medicine in Northeast Florida. This 300+ page coffee table-sized book with over 200 photographs and illustrations recounts the trailblazing history of DCMS and medicine in Northeast Florida. Founded in 1853, DCMS is the first organized medicine group in the state and so its bold claim as the Pioneer Medical Society in Florida is accurate. Authored by Leora Legacy, a DCMS staff member, the book heralds the pioneer initiatives of DCMS and records how its members have been medical trailblazers and forerunners in Jacksonville as well as Northeast Florida for 159 years. Starting with the Timucua Indians and early French and English settlers in Northeast Florida, the book content covers Yellow Fever outbreaks of the 1800s, early physicians in Jacksonville, the founding of DCMS, pioneer Society presidents like Dr. Francis P. Wellford, Dr. Abel S. Baldwin and Dr. R.P. Daniel to other trailblazers like Dr. James Borland, Sr., Dr. Robert McIver and Dr. E. Thomas Sellers, the development from historic medical institutions such as St. Vincent’s, Brewster Hospital and St. Luke’s to Jacksonville’s current medical community, gender and racial diversity breakthroughs, influential partnerships with groups such as the University of Florida , Blue Cross & Blue Shield of Florida and the U.S. Navy, the military involvement and volunteer efforts of Society members, key DCMS leaders and Society initiatives, future plans and visions, plus practice profiles.
(Please print) *Must pre-order by April 15, 2012 to receive price below
Name Address City
Email Quantity/# of copies
Payment - (advanced payment is required): $45.00 per copy $ 3.00 tax $ 6.00 shipping (Sent USPS to home or office) $54.00 Total ($48.00 direct sale and carry)
Check (Payable to The Duval County Medical Society and mailed or faxed/see below) Credit Card (circle one) VISA MC AMEX Discover Expiration date
The Duval County Medical Society/555 Bishopgate Lane, Jacksonville, FL 32204 (P) 904-355-6561 (F) 904-353-5848 (Website) dcmsonline.org
10 Vol. 63, No. 1 2012 Northeast Florida Medicine
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Residents’ Corner: St. Vincent's Family Medicine Editor’s Note: In an effort to connect more Duval County Medical Society members with residents, in each 2012 issue there will be “Residents’ Corner” with information about a residency program in the area, details about research being done and/or a list of achievements/accomplishments of the program’s residents. This “Residents’ Corner” features St. Vincent's Family Medicine Residency Program.
Overview of Residency Program St. Vincent’s Family Medicine Residency Program was developed in 1972 and has been a successful program ever since. The program hosts 30 residents in total, with full-time OBs, a maternity-trained family physician, pediatrician, psychologist, and 10 family medicine faculty. In addition to the full-time faculty physicians, the residents receive teaching from a complete spectrum of private practice physicians who have a dedication to resident education. There are 34,000 clinic visits, 322 deliveries and 2,000 hospital admissions annually. The program emphasizes outpatient care and continuity and is designed to develop critical clinical skills and decision-making abilities. An Electronic Health Record (EHR) has been fully implemented since November 2006. Over 100 graduates are currently practicing in the Jacksonville area. St. Vincent’s Family Medical Center (SV FMC) embraces the patient centered medical home (PC-MH) in its approach to providing comprehensive primary care for children, youth and adults. It has developed the characteristics of the PC-MH by providing each patient with a personal physician who is trained to provide first contact, continuous and comprehensive care, through the use of registries, clinical information systems that track referrals, lab results, and templates to guide clinicians through evidence-based treatment recommendations. SV FMC also supports patient self-management through group visits such as birthing classes, diabetes and renal education classes, and nutrition consultations. Care is coordinated seamlessly from the clinic to the hospital and nursing home. EHR help to reduce medical errors, improve patient care, and facilitate work flow processes for optimal productivity. The Family Medicine Residency Program is part of St. Vincent’s Health System, which was founded by the Daughters of Charity in 1916. St. Vincent’s is a member of Ascension Health, the nation’s largest Catholic and nonprofit health system.
Lara Church,MD PGY3 – received the FAFP 2011 Exceptional Resident Scholar Award Ross Jones, MD PGY3 – President of Florida Association of Family Medicine Residents
Jacqueline Wells, MD PGY2; Silke Natasha Hunter, MD PGY2; Monique Gray, MD PGY1; and Elizabeth Marquez, MD PGY1 – Establishing a protocol to identify breastfeeding rates among our patients and exploring barriers to increasing breastfeeding numbers. They will use this to implement tools to educate patients, physicians, and faculty and increase the current breastfeeding rates.
Sports Medicine – 1) Residents Greg Reichert, DO PGY2; Danielle Carter, DO PGY2; Kirk Grantham, MD PGY3; Deidra Amendola McCafferty, DO PGY3; and Bill McCafferty, DO PGY3; 2) Residents worked with local orthopaedic doctors at high school football games to take care of injuries and decide if the student could continue playing. These same residents participated in the Bumps and Bruises clinic that is held the day after each football game for players with injuries to receive medical care at no cost. Adopt a family – Residents and faculty pitched in to provide holiday meals and gifts to a family in need. Gifts to St. Catherine's – Faculty and Residents brought gifts to the Residents of St. Catherine's Manor. Volunteers in Medicine – Each Resident spends a day seeing patients at Volunteers in Medicine (Clinic for Jacksonville residents who are employed without insurance.) Read and Romp – Family Festival held yearly at St. Vincents to encourage literacy. Each child that comes to our clinic receives an age appropriate book at each well child visit from age 6 months to 5 years and parents are taught age appropriate tools to assist their child in reading. Mobile Health Outreach Clinic – A third mobile unit (purchased and donated by Rotary Clubs of Northeast Florida) was added to the St. Vincent's Mobile Health Outreach Clinic. This "doctor's office on wheels" and two other units provide free medical services to about 30,000 patients a year. Kelli Gahagan, DO, is a graduate of LECOM Bradenton and is currently a 2nd year resident at St. Vincent's Medical Center. She plans to go into private practice in Florida after her graduation in 2013. www . DCMS online . org
Northeast Florida Medicine Vol. 63, No. 1 2012 11
This Issue’s Focus: Addiction Medicine
Addiction: None are Immune Addiction tends to be severely stereotyped, even by the least judgmental of us. No matter what disease we see in our practice of medicine, there is no other disease that evokes such harsh judgment as compared to that placed upon those suffering with drug addiction or alcoholism. Whatever the training or the walk of life from which we have emerged, when hearing the terms addict or alcoholic, it often evokes some of our most unkind thoughts. This is the stigma associated with the disease of addiction and, despite our successes in treatment interventions, we are neither winning the war, nor are we improving our perspective. Are these two failures related? The fact is, this disease knows no socioeconomic boundaries. It can ravage the most highly trained professional, the most well respected politician and the most renowned scholar, just as easily as the less fortunate of our society. Yes, I have known and worked with thousands of those who are considered indigent. And equally disturbing, I have known and worked with thousands of healthcare professionals with this disease. If you were to go to a 12-step meeting, you would see everyone dressed the same and you would hear similar stories; yet, in that meeting room, you will see doctors, lawyers and homeless people speaking to each other with mutual respect and support. There are no differentiators, there is no judgment; just a true caring for one another. There is already so much guilt and shame associated with this disease, Where are these afflicted individuals to go where they will not be judged if help is needed? They are often judged harshly by their family, friends and other associates. The only people guaranteed to be accepting are often those who have the same affliction; a sad statement to make. The other disturbing partner of stigma is denial. Not only do the afflicted suffer with denial, but so does everyone else. Family, friends and co-workers will watch as their loved ones travel deeper and deeper into the darkness of this disease. Often, only when the damage has been done, and there is enough outrage and anger, is anything seriously said about it; by that time, the disease and Raymond M. Pomm, MD Medical Director, River Region its associated guilt and shame have a strong grip on the individual. There is no light that can be Human Services and Gateway seen by this individual, just darkness, and rejection. Where is this person to go? Who will be there to help? How many of you knew such an individual as he/she was traveling down this dark path? Community Services Stigma and denial; we can no longer be partners in the enabling of the suffering if we are to win the war on this disease. We are the leaders, the role models of caring, and oftentimes the ones seeing these individuals as patients. It is our obligation to know as much as we can about this disease in order to bring help as early as possible to our patients in need. They have lost faith in themselves, and believe that their loved ones and their higher power have also lost faith in them; the addicted individual feels so terribly alone, empty and hopeless. The disease might have started as recreational use, fun times or as a result of receiving treatment for acute/chronic pain or anxiety by us, but once that proverbial wall of addiction is crossed, there is no controlling it, because it is now controlling the suffering individual. No amount of willpower is able to stop the rapidly accelerating course! There is one individual often on the front line: their doctor! The medical consequences of addiction that you are treating just add fuel to the fire of this disease. Treating these consequences will not stop the progression. Physicians also have to directly intervene upon and objectively treat this disease. They have to treat patients in a manner that reassures them with care and understanding as well as with an adequate knowledge base. My hope is that this issue will bring a level of enlightenment about this disease to those who might still hold judgment over those who suffer with it. The articles begin with “Addiction for the Non-Behavioral Health Physician: Identification and OfficeBased Strategies for Management,” which I wrote as an overview of the biopsychosocial aspects of this disease with the tools necessary to help you assess your patients and enough information to initiate the first steps toward treatment and recovery in your office. Next is “Addiction Treatment Under Managed Care,” by Jason Jerry, MD and Gregory B. Collins, MD, that analyzes the differences in the types of treatment presently available and gives a review of the factors that influence the direction of treatment in this field. Then “The Physician’s Approach to Substance Use in Adolescents” by Jason B. Fields, MD and Scott A. Teitelbaum, MD, presents the complex issues surrounding adolescent substance abuse as seen through their eyes and expertise. Following is “Methadone Treatment in Pregnancy…That Can’t Be Right, Can It?” by Stacy Seikel, MD, written from a personal perspective after her many years of treating pregnant women who are addicted. Then “Nonpharmacologic Strategies for Treating the Addicted Patient,” by Heidi A. Pomm, PhD, shows how nonpharmacologic intervention can be effectively incorporated into a busy medical practice. Finally, the CME article is, “Domestic Violence Update,” by Nancy Motherway, LCSW; Margaret Ghee, LMHC and myself. (see Insert for CME article) I sincerely hope that this issue brings you a greater level of understanding and knowledge as it pertains to the management of your substance dependent patients. If physicians are to help win this war, by default and necessity, we have to be leaders in this fight. We have to arm ourselves with the tools and resources necessary to do everything we can for our patients. 12 Vol. 63, No. 1 2012 Northeast Florida Medicine
www . DCMS online . org
Addiction for the Non-Behavioral Health Physician: Identification and Office-Based Strategies for Management Raymond M. Pomm, MD Abstract: Through this article I will attempt to help non-behavioral
health physicians become more familiar with several key concepts surrounding addiction. These concepts will include basic neuroanatomy, genetics, pharmacologic principles and specific terms that are important to understand. In addition, the reader will be given tools necessary to assist in the assessment, as well as outpatient detoxification of their own patient, when possible. Unfortunately, the ability to refer your patients to an inpatient detoxification setting is becoming much more difficult and the situation is not likely to improve in the near future. You are on the front line and having the information in this article might be of benefit to both you and your patients.
General Considerations It is important to first review some key facts. The medical establishment is still failing in large numbers to diagnose addictive disease in their patients.1 Nine out of ten primary care physicians do not diagnose substance abuse in patients who display classic symptoms of the disease and this number has not improved.2 In addition, adults and teens with substance use disorders are likely to be the most difficult patients you see in your practice. Common physician reactions to these patients are: Anger, frustration, disgust and apathy. Unfortunately, the increasing incidence of prescription drug abuse and utilization of chronic pain management have only complicated the situation. With all of the prevalent abuses and uses of prescription drugs, the non-behavioral health physician is on the front line. One must be aware of some of the more common substances of abuse that might be found. The following list of substances of abuse is comprehensive, though not complete: • Alcohol • Tobacco • Marijuana including the newer synthetic cannabinoids that are called K2, Spice, etc. • Inhalants • Cocaine (including crack)/stimulants) • Club drugs (i.e. ecstasy, GHB) • Hallucinogens • Opioids • Sedative hypnotics • Sports drugs (i.e. steroids)
Addiction as a Disease It is of utmost importance that the readers of this article understand that all involved specialty societies, including the Address Correspondence to: Raymond M. Pomm, MD, Medical Director: River Region Human Services and Gateway Community Services. 390 Park Street, Jacksonville, FL 32204 (River Region). Email: email@example.com. www . DCMS online . org
American Medical Association, The American Psychiatric Association, The American Association of Addiction Psychiatry and the American Society of Addiction Medicine agree that addiction is a disease. The short definition of the disease of addiction adopted as a public policy statement by the American Society of Addiction Medicine is: “Addiction is a primary, chronic disease of brain reward, motivation and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use or other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”3
Basic Neurobiology of Addiction The processes that initiate and maintain alcoholism and drug addiction are regulated by interactions among nerve cells in the brain. There are various influences that create greater susceptibility to drug usage. Some of these influences include biologic, sociocultural, psychological and environmental. A basic understanding of the neuroanatomy of addiction would be an appropriate next step. Given the limits of this article, a thorough review would best be found in an addiction specific textbook. The greatest activity surrounding addiction can be found in the mesothalamic area of the brain. The key and best understood areas include the ventral tegmental area (VTA), the nucleus accumbens (NA) and the prefrontal cortex (PFC). The VTA is the location of dopamine cell bodies. These cell bodies project their axons to the NA and the PFC (executive control).The NA is also known as the “reward center of the brain”. It integrates the VTA (dopamine) and PFC (glutamine) inputs to determine motivational output: • Incentive (appetitive) • Reward (consummatory) The PFC exerts executive control over the midbrain structures. These structures influence the “conscience “and the “mind”. Each of these areas is activated by specific drugs. For instance, heroin, benzodiazepines and barbiturates act on the VTA. Cocaine, heroin (a second point of activation), nicotine, amphetamines, opioids, and cannabinoids act on Northeast Florida Medicine Vol. 63, No. 1 2012 13
the NA. Alcohol has multiple points of activation throughout the brain. Once the VTA is stimulated through its projections to the NA, the NA becomes activated. Activation of the NA through direct stimulation by the specific drugs listed or by the VTA, sends excitatory signals to the PFC. Of course, this description is very cursory. There is more information on these topics at the following websites: http://www.nida. nih.gov/pubs/teaching.html and http://www.drugabuse.gov/ pubs/teaching.html)
Basic Pharmacologic and Genetic Principles
There are also certain pharmacokinetic basics that need to be understood, both as it pertains to addiction, as well as to detoxification and long term treatment/prognosis. Half-life of abused substances is a very important concept underlying the effect of the drug being used as well as detoxification protocols and urine drug screen. One key factor is that the shorter the half-life and the more rapid the onset of action, the greater the potential for a drug is to be addictive. For instance, fentanyl, alprazolam and crack cocaine have rapid onset of action and relatively short half-lives which make them particularly addictive. Methadone and clonazepam have slower onsets of action and longer half-lives; thereby, making them less addictive. However, methadone and clonazepam are typically abused when the addict/alcoholic is unable to access more addictive drugs of choice. A final note on the subject is that onset of action is partly determined by route of administration. Smoking has a more rapid onset of action than intravenous. Intramuscular injection, less rapid than intravenous, is more rapid than oral administration. As previously mentioned, it is worth noting some of the genetic influences. There is four times an increased risk of addiction in children who are born to parents with an addiction history.4 There is a concordance rate of 60% for monozygotic twins and a concordance rate of 39% for dizygotic twins.5 Adopted children, born of parents with an addiction history, have a four times increased risk in developing addiction over their lifetime, despite the adoptive milieu.6
Terminology It is important to have a reasonable understanding of terminology related to addiction. The term “tolerance” refers to a state in which an organism no longer responds to the drug; a higher dose is required to achieve the same effect. “Dependence” is a state in which an organism functions normally in the presence of a drug but is manifested as a physical disturbance once the drug is removed (withdrawal). One can be dependent upon a drug and not be an addict (For example, an individual who has cancer and requires chronic pain medication.) Many “pain patients” also become dependent without necessarily becoming an addict. The term “addiction” has been described throughout this journal and I 14 Vol. 63, No. 1 2012 Northeast Florida Medicine
refer you to Table 2 in Dr. Fields’ article for the DSM IV-TR definition of Substance Dependence as the formal reference for this term. (see p.23) “Substance Abuse” is also defined in Table 1 of Dr. Fields’ article. (see p.23) A shorter definition I often use for Substance Abuse is when an individual gets into trouble due to substance use on, at least, two different occasions within a twelve month period of time. A very important concept when dealing with the addicted population who might also be suffering with chronic pain relates to the term “pseudo-addiction”. These individuals are often labeled as difficult or drug-seeking patients but their behaviors are a response to under-treatment; often occurring because drug intervals are greater than duration of action. It can be distinguished from true addiction in that the behaviors resolve when pain (or anxiety) is effectively treated. Much more information can be found on this topic in materials related to the treatment of chronic pain and are beyond the purview of this article.
Assessment Tools With a basic understanding of addiction, one can move next to becoming familiar with basic assessment tools that can be utilized in an office-based practice. These tools are readily available online at http://www.samhsa.gov/ or http:// bit.ly/zlmtUj and are in the public domain. The CAGE questionnaire has only four questions, and it is the most widely used instrument. This particular questionnaire only takes 60 seconds and focuses on the lifetime risk. There is a CAGE questionnaire for alcohol use and a CAGE questionnaire for drug use.7,8 (Table 1, p.15) There are two other assessment tools one might want to consider and they are: the MAST, a twenty-four questions instrument related to alcohol, or the AUDIT, a ten question, multicultural instrument. In addition, there are specific opioid assessment tools: The Screener And Opioid Assessment for Patients with Pain (SOAAP); the Drug Abuse Screening Test (DAST); the Opioid Risk Tool (ORT); and the Current Opioid Indices Measure (COMM). All of these instruments are excellent and easily administered. I recommend you choose the one that best fits your practice setting. If one were to consider two different instruments, I would recommend taking one that is more generally related to drugs and alcohol (i.e. the CAGE) and one of the opioid assessment tools. I must emphasize that financial support for inpatient detoxification is dwindling. In addition, the number of indigent beds available for detoxification is usually at capacity. Therefore, more and more pressure is going to be exerted upon the physicians to manage detoxification on an outpatient basis as safely as possible or potentially risk significant sequelae for the untreated patient.
Pharmacologic Strategies: Alcohol One important concept to understand is that alcohol is metabolized at a constant rate no matter how much one is www . DCMS online . org
drinking or how rapidly. It is metabolized at a rate of .015mg% per hour (“0” order kinetics).9 The instruments that are used to analyze the breath yield a direct correlation with blood alcohol level. However, secondary to tolerance, one can see very high blood levels while the individual is walking around seemingly unimpaired. And yet, drinking one or two more drinks can result in coma or death. Conversely, a very low blood alcohol level in the alcohol naïve individual can yield a highly intoxicated state. In an alcoholic, the first 24-48 hours after the last drink is the time during which the individual is at a highest risk for alcohol withdrawal seizures. All alcoholics can experience a “kindling effect” which means that if an individual has had a prior alcohol withdrawal seizure there is a much greater likelihood of having another seizure when going through another episode of withdrawal.10 This risk continues to increase after each episode of withdrawal seizure. The risk for delirium tremens is greatest between day one and day four. Basically, after five days from the last drink, generally speaking, the risks of life threatening withdrawal symptomatology are minimal. There are a few laboratory parameters that can be beneficial in the assessment of the severity of alcohol dependence. “MCV” increases in approximately one quarter of alcoholics. It is often a late sign of alcoholism. The increase can result from both alcohol side effect on folate metabolism and its direct effect on bone marrow. It increases with higher alcohol consumption and remains elevated for months after cessation of drinking. “GGT” (gamma glutamyl transferase) is increased in approximately 2/3 of alcoholics. This is a sensitive index but not specific for alcohol or drug toxicity to the liver. Heavy alcohol use over several weeks or longer induces GGT. Levels return to normal after approximately 3 weeks of abstinence. A urine drug test called Ethyl Glucuronide (ETG) can be positive for up to five days after drinking alcohol. In my experience, levels between 250 and 500 ng/ml are of questionable validity; however, levels of 500 and above yield much more consistent and valid results. This urine drug screen test can be beneficial in determining if your patient is continuing to drink. An excellent assessment tool that also uses the withdrawal signs and symptoms of alcohol is called the CIWA-Ar (Table2, web illistration, see dcmsonline.org under this article's title,).11 The basic parameters to consider while using this instrument are: • <10 – no pharmacologic intervention • 10-20 – clinical judgment; though, I typically begin a protocol at 10. • >20 – definite intervention If one were going to attempt alcohol withdrawal on an outpatient basis, several criteria must be considered: • Not a life-threatening situation (no prior seizure history or delirium tremens) • Stable support system (family, significant other, etc.) • Stable income • Responsible person to drive back and forth to your office and manage the medications • He/she is a very motivated patient www . DCMS online . org
Table 1 CAGE Questionnaires
Questions for drug use: • Have you felt [Do you feel] the need to Cut down on your alcohol or drug use? • Have people Annoyed [Do people Annoy] you by criticizing your use of alcohol or drugs? • Have you ever felt [Do you feel] bad or Guilty about your alcohol or drug use? • Have you ever needed [Do you ever need] an Eyeopener to steady your nerves or get rid of alcohol or drug aftereffects?
(Adapted from Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. Oct 12 1984; 252(14):1905-1907.) Note: The scoring is the same as the CAGE Questionnaire. for alcohol use. Developed by Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, CAGE is an internationally used assessment instrument for identifying alcoholics. It is particularly popular with primary care givers. CAGE has been translated into several languages.The CAGE questions can be used in the clinical setting using informal phrasing. It has been demonstrated that they are most effective when used as part of a general health history and should NOT be preceded by questions about how much or how frequently the patient drinks (see “Alcoholism: The Keys to the CAGE” by DL Steinweg and H Worth; American Journal of Medicine 94: 520-523, May 1993.)
I usually begin this protocol on a Monday and have the patient visit daily for a CIWA assessment by you or your nurse. The typical protocol while using chlordiazepoxide is: • 50 mg q.i.d. for two days, then • 50 mg t.i.d. for two days, then • 50 mg b.i.d. for two days, then • 50 mg q.d. for two days This protocol has been used by me for years and proven to be very safe. During days one and two, it is permissible to use 1-2 mg of lorazepam p.r.n. between doses. In addition, for comfort purposes, as long as the patient is not overly sedate and is compliant, there is no reason one cannot extend this protocol at any point for a greater number of days. In fact, one can go back to the prior step of the protocol and resume at any point in time. However, I must underline the importance Northeast Florida Medicine Vol. 63, No. 1 2012 15
of having a responsible person managing the medications. There are other supportive measures to be considered. A daily multivitamin and appropriate nutritional support is very important. There is some evidence that 100 mg of thiamine daily for up to one year is recommended.
Pharmacologic Strategies: Benzodiazepines Benzodiazepines, as far as withdrawal is considered, are very similar to alcohol. In fact, one would use the same assessment tool: CIWA-AR. One would also use the exact same parameters for initiating treatment as noted above for alcohol. Aside from urine drug testing, there are no laboratory parameters that can be recommended. However, urine drug testing for benzodiazepines is important to understand. Be certain that the laboratory, or other testing methods being used, test for all the different types of benzodiazepines beyond the diazepam metabolites. Many tests do not yield results for alprazolam or lorazepam. It can also be very difficult to also obtain valid results for clonazepam. Obtaining the levels of benzodiazepines through urine drug testing is typically only beneficial if one sees decreasing levels or absence of the drug itself. Blood testing is not beneficial. A very important concept to understand regarding benzodiazepines is half-life. One of the most frequently abused benzodiazepines is alprazolam. Its half-life is 11-16 hours. Unfortunately, within a matter of days an individual can become tolerant to alprazolam and begin to experience interdose withdrawal symptoms. These withdrawal symptoms are almost identical to, and at times worse than, the very symptoms for which the medication was originally prescribed. The approximate timetable for risks regarding seizures and delirium tremens resembles that of alcohol. Basically, one to two days from last use is the highest risk for seizures. In addition, the “kindling effect” is as relevant for these drugs as it is for alcohol. Half-life also pertains to urine drug testing as it takes five half-lives for a drug to leave the system. In my experience, the most effective drug to use for withdrawal from alprazolam is clonazepam. The ratio is approximately 1:1 (1 mg of clonazepam for 1 mg of alprazolam). There are two basic protocols that I have found very safe and effective. For those individuals using upward of 4-6 mg of alprazolam per day I utilize 1 mg of clonazepam q.i.d. and decrease by one half milligram q.d. until d/c. For those using greater than 6 mg of alprazolam per day I utilize 2 mg of clonazepam q.i.d. and decrease by 1 mg q.d. until d/c. The parameters for utilizing an outpatient venue for benzodiazepines are no different than for alcohol (see “Pharmacologic Strategies: Alcohol “). Again, extending the time out for the protocol, as long as the patient is compliant and there is someone managing the medications, is a reasonable option. In discussing the long half-life benzodiazepines, such as diazepam, the approach is somewhat different. First, because 16 Vol. 63, No. 1 2012 Northeast Florida Medicine
of the long half-life one might not even see withdrawal symptoms for up to six or seven days after stopping the medication. The risk for seizure is extended out just as long. In the case of diazepam or clonazepam, one can use the same medication (diazepam or clonazepam) for the detoxification process. In this case, the dose reduction rate is 10% reduction per day (the 10% is based upon the initial amount of drug being used and kept consistent throughout the withdrawal process; therefore, a process of ten days). Extending the time out for these medications is also a reasonable option given the same parameters of a reliable individual managing medications and a compliant patient. It is worthwhile noting that there are many patients on benzodiazepines that are not addicts. However, they might be dependent upon the drug. The management of these individuals can be undertaken by the non-behavioral health doctor; however, the important consideration is that there is no rush. Please go as slow as needed, even months, to slowly wean your patient. Be certain however that you initiate a nonaddictive treatment for the original condition being treated (i.e. anxiety disorder) prior to beginning the weaning process.
Pharmacologic Strategies: Opioids I am using the term opioids to encompass all narcotic analgesics that are mu receptor agonists. Mu receptor agonists also act on the Locus Coeruleus. By shutting down the activity of this area of the brain, there is a dramatic decrease in sympathomimetic activity. Unfortunately, when one takes away the opioid, there is a rebound in sympathomimetic activity which underlies a significant proportion of withdrawal symptoms. COWS, is an instrument that can be used to assess the level of withdrawal just as one in would use the early mentioned CIWA-Ar. A score of 10 or greater would be a good indicator to initiate treatment. (Table 3, web illustration, see dcmeonline. org under this article's title.)12 As with benzodiazepines, there are no laboratory markers associated with opioid dependence and withdrawal. Urine drug screening is an excellent way to determine if an individual has stopped using opioids. The important factor here is that you need to be certain that the laboratory or testing method being utilized tests for both morphine/codeine metabolites as well as synthetic opioids. Even with that level of testing, one would also want to be certain to include tramadol and methadone as they are typically not tested for in routine opioid urine panels. Buprenorphine is typically not abused, though I have been finding it is used by opiate addicts when they run out of their typical drug. Buprenorphine is available for urine drug testing when asked. The medication of choice I use for detoxification from opioids is baclofen. I successfully use this medication by giving 10-20 mg every six hours for 5-8 days. When necessary, I may combine clonidine with baclofen, giving 0.1 mg t.i.d. p.r.n. (assuming tolerability of their blood pressure) for up to five days. This protocol can safely be performed on an outpatient basis given all the above parameters that have www . DCMS online . org
already been discussed for alcohol and benzodiazepines. Supportive measures during detoxification can include a p.r.n. NSAID, lorazepam 0.5-1 mg t.i.d. p.r.n. for the first three days only and promethazine (or similar antinauseant) as per direction for three days. In addition, Suboxone can be safely used to detoxify opiate addicts or to maintain them on it from your office-based practice. In order to prescribe this medication for this purpose, one must take a course and apply for a special DEA number. This process can be started by going to the Substance Abuse and Mental Health Services Administration website for further information. (http://www.samhsa.gov/) I strongly urge all of you to consider taking the course and applying for the ability to prescribe this medication. Access to this medication can yield tremendous benefits for your patients.
drugs and alcohol. A close relationship with a sponsor can be invaluable to preventing relapse. There could be other forms of support your patient might choose and you cannot legally expect any one over another. The important thing to remember is that no matter what support your patient chooses, s/he must be honest with his/ her support system about their problem with drugs and/or alcohol. It is always best that the support system chosen has personal experience with addiction and offers their support in a non-judgmental manner.
Markel H. Treatment for Addiction Meets Barriers in the Doctor’s Office, New York Times, Health, October 21, 2003.
Markel, H., Califano J., Treatment for Addiction Meets Barriers in the Doctor’s Office, New York Times, Health and Fitness, October 21, 2003.
Public Policy Statement: Short definition of Addiction, Adopted by the ASAM Board of Directors, 4/12/2011, copyright 2011.
Schuckit, MA, Goodwin DW, Winokur GA. A Study of Alcoholism in Half-Siblings, AMJ Psychiatry 1972;128:11321136.
Kaij L. Studies on the Etiology and Sequelae of Abuse of Alcohol. Lund, Sweden:University of Lund Press; 1960.
Please remember that detoxification is not treatment. Once your patient has been successfully detoxified, referral for assessment as to the appropriate level of treatment would be warranted. Go to http://www.fadaa.org/ for a listing of providers in your area). In addition, whether your patient goes to treatment or not, a recovery program is the key to long-term success. The 12-step programs offer hope and support for patients and therefore are more successful. You might know these programs as Alcoholics Anonymous or Narcotics Anonymous (http://www.aa.org/ or http://www.na.org/). It is very important to ensure that the family has access to support through whatever treatment center is involved and/or Al-Anon (http://www.al-anon.alateen.org/)would be very important.
Schuckit, MA, Biological Vulnerability to Alcoholism. J Consult Clin Psychol 1987;55:1-9.
Ewing, JA. Detecting Alcoholism: The CAGE Questionnaire. JAMA 1984; 252:1905-1907.
Brown, R.L., and Rounds, L.A. Conjoint Screening Questionnaires for Alcohol and Drug Abuse. Wisconsin Medical Journal .1995; 94:135-140.
American Society of Addiction Medicine: Principles of Addiction Medicine, Fourth Edition. Philadelphia PA, Lippincott Williams and Wilkins, 2009:73-74, 86.
I would like to include a few words about some of the other potential drugs of abuse. Marijuana, crack and powder cocaine, hallucinogens, and amphetamines typically don’t require a specific detoxification protocol unless other more serious symptoms, such as psychosis, are evident. I would refer patients for inpatient management in these circumstances. In addition, carisoprodol and barbiturates would also require inpatient detoxification.
Whether your patient has been discharged from treatment or a detoxification program, asking if s/he is involved in a program of recovery is very important. If s/he says “no”, I suggest that you strongly recommend trying a 12-step program. Once going to meetings, it is important to ask if s/he is continuing to attend and how many meetings are being attended per week. Compliance with meeting attendance can be very important to long term recovery. Another question that is important to ask of your patient pertains to having a sponsor. A sponsor should be of the same gender and there should be regular contact between them. A sponsor is a person who has a significant time in recovery and also attends 12-step meetings. This individual is someone your patient can contact at any time for support and to discuss difficulties that they encounter in a life without www . DCMS online . org
10. Becker, H.C. Kindling in Alcohol Withdrawal. Alcohol Health and Research World .1998;22,No.1:25-33 11. Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of Alcohol Withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). British Journal of Addiction, 1989;84:1353-1357 12. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs. 2003;35(2):253-59.
Web Illustrations for this Article Tables 2 & 3 of this article are not published in the journal's print version. Please go to dcmsonline.org, click the journal cover and the complete article with the tables will be included in the pdf.
Northeast Florida Medicine Vol. 63, No. 1 2012 17
Addiction Treatment Under Managed Care Jason Jerry, MD and Gregory B. Collins, MD Abstract: Addiction is a chronic, life-long illness that requires ongo-
ing care. “Detox” is not synonymous with addiction treatment, and the real work of recovery doesn’t start until detoxification is completed. Detoxification, usually accomplished on an inpatient unit, is merely the medical stabilization piece that precedes entry into more formal addiction treatment. The other components of addiction treatment fall along a continuum that includes: inpatient residential treatment (the most intense and restrictive), partial hospitalization and intensive outpatient treatment (the least intense and restrictive). In an attempt to manage increasing costs, managed care with the advent of evidence based medicine developed pathways that favored outpatient programs rather than the traditional inpatient residential models. The authors experience indicates this will likely result in other non-behavioral health providers playing a more central role in providing outpatient care for those suffering from alcoholism or drug addiction.
Levels of Care and Economic Pressures Inpatient detoxification has historically been the starting point for most chemically dependent patients seeking help. This stage of treatment is often provided in hospitals, but also takes place on specialized units in chemical dependency treatment centers. The primary task of detoxification is to safely transition the patients off of whatever substances they were taking, while minimizing any potential medical complications associated with withdrawal syndromes (seizures, alcohol withdrawal delirium, etc.). This detoxification is typically accomplished by giving tapering doses of medications that act at the same Central Nervous System (CNS) receptors as the patient’s drug of choice and gradually tapering down slowly enough so that the brain has enough time to equilibrate and re-establish homeostasis. Detoxification is, therefore, not to be confused with addiction treatment as it merely serves to medically stabilize the patient so that he or she can participate in less intensive levels of care for rehabilitation, or better yet, recovery. Until recently, detoxification for alcohol or sedative dependence has not been a major point of contention between managed care organizations and treating physicians. In the past, if a doctor felt that a patient needed close medical supervision during the detoxification process, inpatient days were generally approved for reimbursement. Prior to 2003, the same was generally true with regard to opiate dependent patients who could really only tolerate withdrawal during their detoxification with tapering doses of long-acting, highly restricted opioids like methadone that posed a real risk for overdose if provided in a less-structured environment.
Address Correspondence: Jason Jerry, MD, The Cleveland Clinic, Alcohol and Drug Recovery Center, 9500 Euclid Ave., P57, Cleveland, OH 44195. Email:JerryJ@ccf.org. 18 Vol. 63, No. 1 2012 Northeast Florida Medicine
Eight years ago, a much safer alternative to methadone, Suboxone®, (buprenorphine/naloxone) was approved for the treatment of opioid dependence. It is a medication that, because of its partial-agonist mechanism of action, has a ceiling effect on respiratory depression that greatly reduces its potential for fatal overdose. Furthermore, its use in addiction treatment is not restricted to methadone clinics, and Suboxone® prescriptions can be written by doctors who have received special training and who have obtained a Drug Enforcement Agency (DEA) waiver to prescribe this medication. The net result of these developments has been a significant change in medical/behavioral health guidelines based on the realization that opioid detoxification can often be safely conducted on an outpatient basis through the provision of Suboxone® in a private doctor’s office. The other issue that has impacted the push for outpatient treatment of opiate dependence is the robust literature that clearly suggests that patients who are maintained on methadone or Suboxone ® fare better than those who try to recover without medications.1,2,3,4,5 Though methadone or Suboxone® maintenance may be the preferred choice for most opiate-dependent individuals, it is often difficult to place patients into such services at their time of need when they present, as they often do, to an emergency department in acute withdrawal. Methadone clinics are many times not available to patients who are sitting in emergency rooms at their times of crisis. Suboxone® providers in the community often will not accept insurance, let alone Medicaid, and the medication is expensive, so Suboxone® maintenance may be out of reach for many in spite of its efficacy in reducing relapse. Due to literature indicating low mortality in opiate withdrawal and attempts to manage costs, managed care organizations will typically not pay for inpatient opiate detoxification. As appropriate, physicians should argue that drug abuse and addiction inherently carry a high mortality risk as well as many risks to the community at large, so hospitalization may be required for safety and for the management of medical or psychiatric comorbidities. In contrast to opiate dependence, alcohol and benzodiazepine dependence have typically received more favorable treatment decisions with regard to insurance coverage. After all, who would want to go against a treating physician’s opinion regarding a withdrawal syndrome that carried with it the real risk of withdrawal seizures, delirium tremens, and potentially, death? The managed care industry has come to realize, however, that not all alcoholics develop the type of physiologic dependence that places them at risk for such medical complications and that many can be managed with minimal risk in an outpatient setting. The actual level of risk often can be ascertained during a 23-hour “observation” admission on an inpatient unit. With regard to benzodiazepines, treating
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physicians know that the use of antiepileptic medications, alone or in conjunction with long-acting benzodiazepine tapers, have made the provision of benzodiazepine detoxification a relatively safe endeavor that can often be accomplished in an outpatient setting. When dealing with these issues, physicians should emphasize that the feasibility of providing such care hinges on the level of support available in the home environment. Outpatient detoxification, because of its inherent risks, requires the involvement of a very supportive family to closely monitor the patient at home for medication compliance, to guard against the use of non-prescribed substances, and to watch the patient for severe withdrawal symptoms or adverse reactions. The reality is that many, if not most patients don’t have such supportive environments, and managed care organizations should take such considerations into account when making determinations for reimbursement. So, although managed care guidelines require justification for inpatient care, the physicians must still evaluate the larger picture and recommend (and advocate for) the appropriate level of treatment. A residential level of care is often the next step following detoxification. This level involves housing the patient within a highly structured and closely monitored dormitory-like environment within the treatment facility (usually, a non-hospital setting). Patients have daytime programming that involves group and individual therapy, occupational therapy, nursemonitoring for ongoing withdrawal or possible side-effects from medications, and, in some cases, psychiatric services for the management of any co-morbid psychiatric conditions. Such levels of care have typically been employed when there is a need for the close monitoring of patients, either because they are psychologically fragile or because their drug or alcohol addiction was so severe that it is clear that they would not be able to maintain abstinence outside of a highly structured environment. Historically, a 28-day inpatient model (the Minnesota Model) has prevailed, but with the use of non-hospital settings, most residential programs advocate long lengths of stay, typically 30 days or longer, often driving up the cost.6 The relatively high cost of residential care, and a “one size fits all” application of its use to treat most patients with addiction in the 1980s, led to a push in the 1990s for more outpatient care. Several treatment centers in Florida began marketing the next lower level of care, partial hospitalization programs (PHPs), as though they were residential treatment by coupling day treatment programs with off-site housing. Such “Florida Model” programs would typically have apartment complexes separate from the treatment center where the patients would sleep plus transportation to the facility during the day for their groups and meetings.7 This move, in effect, shifted the boarding costs from the insurance company to the individual or to the treatment provider, while still allowing for residential-like treatment. Insurance will often pay the cost of the partial hospitalization or intensive outpatient levels of treatment. In many (if not most) PHPs, patients are expected to have www . DCMS online . org
their own housing arrangements and come to the facility for treatment for 8-12 hours per day. Unlike residential programs, there is typically no programming on the weekend. Unfortunately, the potential pitfall with this level of care is that if patients are still very fragile and vulnerable to relapse, a two-day break in their treatment can cause treatment failure. Nonetheless, strict interpretation of guidelines results in patients step down from residential levels of care and into a less expensive “Florida Model” program or traditional PHP. Based on the authors’ experience, the argument here is that patients neither have medical acuity nor need to be on medications that would warrant 24hr nurse monitoring in a structured environment, seven days per week.7 Below PHP in time allotment, cost, and intensity, is the intensive outpatient program (IOP). This type of program provides therapy three to four hours per day, three to five days per week. They were initially created as post-discharge programs to maintain the goals that the patient achieved while in residential treatment or PHP. Under cost pressures, such programs are now often being used as first-line options for individuals coming out of detoxification (or in those not requiring detoxification). This is not surprising given that they are the least costly addiction treatment options. Some insurance companies require that the patient has to try and fail at IOP treatment first before PHP or inpatient care will be authorized and covered.8
Managed Care and Evidence Based Medicine
As health care costs soared, managed care developed guidelines for medical necessity for the traditional 28-day Minnesota-model inpatient programs, which favored outpatient levels of care during the early 1990s. This change was based on research that showed no difference in outcomes for inpatient or outpatient care. This research involved patients who were not randomly assigned, so in reality, patients who chose outpatient did better than or as well as those who chose inpatient. 9,10 Therefore, outcomes could be skewed by the fact that less sick patients chose outpatient care and did well, and sicker patients chose (or needed) inpatient care, and did less well. As a result, the notion that “outpatient care works just as well as inpatient care,” should be challenged in the authors’ opinion. The more favored outpatient care was also driven by outcome research under indemnity insurance plans that showed that in the 1980s many patients were being treated according to the maximum benefit allotted by their insurance policies, and there was no proof that higher levels of care were superior.11,12 The end result is that, doctors are faced with having to prove that a particular treatment is sorely needed in order to be reimbursed. This can be frustrating when the physician feels strongly that an individual patient is doomed to fail without the treatment in question. Another problem with the outcomes research on various levels of care in addiction treatment is that these studies generally compare the outcomes of groups of individuals going Northeast Florida Medicine Vol. 63, No. 1 2012 19
through one level of care versus another or for various lengths of time. The point is that studies seldom watch individual needs and co-morbid issues for each patient.13 Asking whether inpatient treatment works for alcohol dependence is like asking if radiation treatment is effective for cancer. Treatment has to be tailored to the individual needs of the addict or alcoholic just as radiation, chemotherapy, and surgical interventions need to be tailored to the particular type of cancer. If, for instance, an alcoholic has a stable home environment with a loving, supportive family, a high level of motivation to get well, and no psychiatric comorbidity, inpatient residential treatment may not be indicated at all. This type of patient may do very well by attending Twelve-Step meetings, obtaining a sponsor, and following up on a routine basis with an addictions specialist.
Future of Addiction Treatment Like it or not, insurance coverage for a 28-day residential treatment program is increasingly rare, so this option is often out of reach unless the patient wishes to pay out-of-pocket. In an odd way, it seems like we have returned to the 1940s when Alcoholic’s Anonymous was in its infancy. At that time, alcoholics needing detoxification were placed in a general hospital for a few days and, upon discharge, stayed sober by going to 12-step meetings. The situation is more worrisome for patients addicted to opiates where the risk of fatal overdose is so high in the outpatient setting. The use of opioid pain medications has skyrocketed such that opiates are now the second most abused drug in America behind marijuana.14 As of 2007, accidental poisonings became second only to motor-vehicle crashes as the leading cause of accidental or unintentional death in the United States.15 In Florida, the death rate secondary to prescription drug overdose increased by 84.2% from 2003 to 2009. Fortunately, medications such as Suboxone and naltrexone (Vivitrol) are now available and provide some protection to these very vulnerable opiate-dependent patients. These medications and others have the potential to help such patients stay in an outpatient recovery program long enough to effect long-lasting change.4,16
Role of Non-Behavioral Health Physicians in Addiction Treatment With regard to the future of addiction treatment, nonbehavioral health physicians and more specifically primary care physicians (PCPs) will likely play an ever-increasing role in providing care. Due to the aforementioned cost issues and, unless you practice in an urban area, PHPs and IOPs will be hard to find. Therefore, non-behavioral health physicians become more important for an addicted individual in need. While many physicians may have an aversion to treating addicted patients, the statistics are clear. One out of every 20 Vol. 63, No. 1 2012 Northeast Florida Medicine
five to ten patients in general practice has an alcohol use disorder.17 The approach to such patients in the past had always been to screen those who were suspected to be at risk, and if they screened positive for possible alcohol dependence, to refer them to an addiction specialist. The old paradigm, in summary, was essentially not to ask questions until it became pretty obvious that the patient was an alcoholic and then send the patient to a specialist who could help in achieving abstinence. There is, however, an approach that has been developed for general practice that has shown promise in addressing alcohol consumption along the continuum between social drinking and alcohol-dependence. Screening, brief intervention, and referral to treatment (SBIRT) is a 5 to 20 minute clinical approach to uncovering problematic drinking with a focus on reducing alcohol consumption (rather than achieving total abstinence) while referring those patients who meet criteria for alcohol dependence to addiction treatment specialists. Screening and brief intervention (SBI) is an approach that has been used in clinical practice for years to approach a wide array of problematic behaviors such as poor medication compliance, dietary issues, lack of exercise, and smoking. 17 Screening starts by asking the patient if he or she ever drinks wine, beer, or other alcoholic beverages. Further questions explore how many times in the past year the patient has engaged in problematic drinking, defined as five or more drinks per occasion for men under 65 and four or more drinks per occasion for women and men who are 65yrs or older. These questions can then be followed by a formal CAGE (http://bit.ly/yAMDXc) questionnaire or an Alcohol Use Disorders Identification Test (AUDIT) to help ascertain the severity of the problem.17,18,19 Patients who meet criteria for alcohol dependence are advised to abstain from alcohol, attend 12-step meetings, and are provided with a referral to an addiction treatment specialist. With those who do not meet criteria for alcohol dependence, the brief intervention part of SBIRT involves providing concrete advice to the patient that he or she should cut down on drinking while assessing readiness to change behavior and working on the establishment of a drinking goal. While only a very brief overview of SBIRT has been provided in this article, a more detailed review can be found in a booklet from the National Institute on Alcohol Abuse and Alcoholism entitled “Helping Patients Who Drink Too Much: A Clinician’s Guide.” (http://1.usa.gov/B3vfP.) Studies have shown that SBIRT can reduce one-year alcohol consumption by 10-30% in clinical practice and can save three to four dollars in healthcare costs for every dollar invested in SBIRT programs.20,21,22 Unfortunately, SBIRT has not been shown to be effective with patients who suffer from opiate use disorders. Detecting opiate use problems can be difficult, especially if such patients are being treated for a chronic pain issue. Typically, the use of treatment contracts combined with routine or random www . DCMS online . org
urine toxicology screens has been the mainstay of addressing this issue. Additionally, there has been a big focus on being mindful of aberrant behaviors that are strongly associated with problematic use of opiates. A study by Fleming, et al. in 2007, as an example, revealed that four behaviors were highly correlated with abuse or addiction: sedating oneself, using narcotics for non-pain reasons, increasing narcotic dose without doctor’s approval, and experiencing the feeling of intoxication on narcotics.23 When problematic behavior is identified in patients who are on narcotics, they should be referred to an addiction treatment specialist for a more thorough evaluation and for possible treatment.
Conclusion Patients with addiction problems can no longer be simply whisked away to inpatient treatment centers to be dealt with by a mysterious process that we call recovery, initiated in a proverbial black box traditionally referred to as “rehab.” Regardless of specialty, doctors need to be proficient in screening for drug and alcohol use disorders and in using basic front-line treatments for such individuals. Physicians should become familiar with addiction treatment specialists in their geographic area, as well as locations and times of local twelve-step meetings (http://aa.org/lang/en/subpage. cfm?page=28), methadone clinics (http://dpt2.samhsa.gov/ treatment/directory.aspx), and with doctors who are able to provide Suboxone® treatment to opioid dependent individuals (www.suboxone.com).
Ball JC, Ross A. The effectiveness of methadone maintenance treatment . New York: Springer-Verlag, 1991:283
McLellan AT. Patient characteristics associated with outcome. In: Cooper JR, et al. (eds.). Research on the treatment of narcotic addiction: state of the art. Rockville, MD: National Institute on Drug Abuse Treatment, Monograph Series, 1983:500-529.
Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2003;CD002209 Mattick RP, Kimber J, Breen C, Davoli M. Buprepnorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2008;CD002207
Fudala PJ, Bridge P, Herbert S, et al. Office-based treatment of opioid addiction with a sublingual-tablet formulation of buprenorphine and naloxone. NEJM 2003: 349(10); 949-958.
Barthwell AG, Brown LS. The treatment of drug addiction: an overview. In: Ries RK, et al. (eds.). Principles of addiction medicine, 4th ed. Philadelphia, PA: Lippincot Williams and Wilkins, 2009:352-353
Jackson T. South Florida a booming market. Treatment Magazine: Addiction Industry News. February, 2010. Available at: http://www.treatmentmagazine.com/special-reports/134-abooming-market.html Accessed: November 14, 2011 Mee-Lee D, Shulman GD. The ASAM placement criteria and
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matching patients to treatment. In: Graham AW, Schultz TK, Mayo-Smith M, Ries RK & Wilford BB, (eds.) Principles of Addiction Medicine, 3rd Ed. ASAM, Chevy Chase, MD 2003. page 457 9.
Hubbard RL, et al. Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press; 1989
10. Fletcher BW, Battjes RJ. Introduction to the special issue: Treatment and process in DATOS. Drug Alcohol Depend 1999;57:81-87. 11. Holder HD, Longabaugh R, Miller WR, Rubonis A. The cost effectiveness of treatment for alcoholism: a first approximation. J Stud Alcohol 1991;52:517-540. 12. Miller WR and Hester RK. In-patient alcoholism treatment: who benefits. Am Psychol 1986;41:794-805 13. Mechanic D and McAlpine DD. Mission unfulfilled: potholes on the road to mental health parity. Health Aff 1999; 18(5):7-21 14. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 national survey on drug use and health: Volume I. Summary of national findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4856). Rockville, MD 15. CDC. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at http://www.cdc.gov/injury /wisqars/ index.html. Accessed: December 30, 2011. 16. Krupitsky E, Nunes EV, Ling W, Illeperuma A, Gastfriend DR, Silverman BL. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet 2011; 377: 1506-1513. 17. Zgierska A and Fleming MF. Screening and brief intervention. In: Ries RK, et al. (eds.). Principles of addiction medicine, 4th ed. Philadelphia, PA: Lippincot Williams and Wilkins, 2009:267-268 18. Babor TF, et al. AUDIT. The alcohol use disorders identification test. Guidelines for use in primary care, second edition. Geneva: World Health Organization, 2001. Available at: http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a. pdf Accessed: December 30, 2011 19. Ewing JA. Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association. 1984; 252(14): 1905-1907 20. Whitlock EP, Polen MR, Green CA, et al. U.S. Preventive Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004; 140:557-568. 21. Kaner EF. Effectivenesss of brief alcohol intervention in primary care populations. Cochrane Database Syst Rev. 2007; 18(2): CD004148. 22. Fleming MF. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26(1):36-43. 23. Fleming MF, Balousek SL, Klessig CL, Mundt MP, and Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 2007; 8(7): 573-582.
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The Physician's Approach to Substance Use in Adolescents Jason B. Fields, MD and Scott A. Teitelbaum, MD Abstract: Substance use in adolescents is a significant public health
problem. Many surveys and studies indicate that substance use is highly prevalent among the adolescent population. The physician can make a significant difference in the quality of life of their patients by identifying problematic substance use as early as possible. Clinicians should be familiar with available professional resources in their community to assist in treatment of their patients. This article seeks to provide helpful information for the physician who encounters adolescent patients with substance abuse issues.
Introduction There are multiple genetic and environmental risk factors that make adolescents more likely to initiate substance use. Subsets of these adolescents eventually develop substance use disorders which are associated with significant health, academic, and legal consequences. The vast majority of adults who meet the criteria for addiction began to use tobacco, alcohol, marijuana, and other drugs prior to the age of 18. Physicians potentially play a key role in early identification of adolescents with problematic substance use. Older children and adolescents should have substance use screening as soon as they are old enough to be interviewed without a parent present. The CRAFFT questionnaire is a recommended reliable screening tool that is practical for the clinician. With a positive screen, the clinician should initiate an assessment to gather important information to assist the staging of substance use. The clinician can then make appropriate interventions and referral for treatment if warranted.
Definitions and Epidemiology The term “Substance use” has been proposed by The Substance Abuse and Mental Health Services Administration (SAMHSA) as minimal or experimental use with minimal consequences. “Substance abuse” is regular use that has a negative impact on daily functioning or that is associated with recurrent significant problems. “Substance dependence” is a syndrome associated with loss of control over the use of a drug.1, 2 The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Rev. (DSM-IV-TR), is a guideline for assessing problematic substance use (Table 1 and Table 2, p.23).3 According to the National Institute on Drug Abuse, (NIDA), addiction is a chronic disease with genetic, environmental, and behavioral components. As a chronic disease, it often begins during adolescence and early onset of substance use is highly predictive of a future substance use disorder.4 Address Correspondence to: Jason B. Fields, MD, UF Fellow in Addiction Medicine, Medical Services Manager DACCO, 4422 E. Columbus Dr., Tampa, FL 33605. Phone: 910-431-4614. Fax: 813-612-9373. Email: firstname.lastname@example.org. 22 Vol. 63, No. 1 2012 Northeast Florida Medicine
The “Monitoring the Future” survey is a national survey of drug use that has been administered annually since 1975 and it offers a comprehensive view of the factors that influence drug use.1 Substance use (alcohol and illicit drugs) rates have stabilized in recent years with the exception of marijuana, which has shown an increased trend in use over the last 2 to 3 years (Figure 1, web illustration, see dcmsonline.org under this article's title). Annual prevalence rates for 2010 for any illicit drug use in grades 8, 10, and 12 are high at 16%, 30% and 38%, respectively.5 The two most common substances used by adolescents are alcohol and marijuana, with annual rates for senior high school students at 66% and 35% in 2010.5 Marijuana has been the most common substance of daily use among adolescents for over a decade.6 By their senior year in high school, it is estimated that 80% of adolescents have begun to drink and 50% have used an illicit drug.4 Prescription drug misuse (use of a medication in any way other than prescribed) is high among high school seniors at an annual rate of 15%.6 In 2005, prevalence estimates for abuse or dependence of illicit drug was 4.7% and the rate of alcohol abuse or dependence was 5.5%.2 Earlier use of alcohol and drugs is more likely to result in substance use disorders in adulthood.7, 8 Substance use before age 18 is associated with an eightfold greater likelihood of developing substance dependence in adulthood.2 According to the National Center on Addiction and Substance Abuse (CASA), 9 in 10 people who meet the criteria for addiction began to smoke, drink and/or use other drugs before age 18. The same CASA report found that 1 in 4 Americans who began using any addictive substance before age 18 are addicts, compared to 1 in 25 Americans who started using at age 21 or older.8 Physicians can potentially make a difference in education on substance use as one study found that only 35% of adolescents reported discussing substance use with their primary care physicians while 65% of the sample indicated they wanted to.2 About 75% of adolescents visit a physician at least once a year, with an average of 2.5 visits per adolescent. In addition, physical and mental health problems often accompany substance abuse which makes the physician’s office an ideal setting for early identification and intervention for adolescent substance abuse.9 The American Academy of Pediatrics (AAP) recommends routine yearly screening of all adolescents for substance use at the annual well-child visit.4,9 Youth who engage in drug and alcohol use at a young age are at higher risk of lifelong negative consequences that include academic failure, chronic health problems, and violent crime. Substance use is strongly associated with the leading causes of death among US teenagers including motor vehicle crashes, unintentional injuries, homicides and suicides.10 Substance use also contributes to a large number of other health problems, such as depression, conduct disorder, and unplanned sexual activity.4 www . DCMS online . org
Table 1 DSM-I V-TR Criteria for Substance Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
Table 2 DSM-I V-TR Criteria for Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance (2) withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (3) the substance is often taken in larger amounts or over a longer period than was intended (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use (5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chainsmoking), or recover from its effects (6) important social, occupational, or recreational activities are given up or reduced because of substance use (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
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During early adolescence, substance use occurs almost exclusively in a social context. Experimentation often begins with “gateway” drugs that are readily available, such as tobacco, alcohol, and inhalants.11 Research shows that if adolescents use tobacco or drink alcohol, they are 65 times more likely to use marijuana than children who never smoked or drank. Also, marijuana use translates to an individual being 104 times as likely to use cocaine compared to peers who never used marijuana.12
A Population at Risk There are individual, family, peer and school factors that play a role at putting adolescents at risk for substance use. Cognitive risk factors include lack of knowledge about the risks of substance use and believing that use is “normal.”1 It has been estimated that approximately 20.8% of high school students think marijuana is a harmless drug.8 Research has established that the adolescent is vulnerable to addiction from a neurodevelopmental standpoint. Repetitive use causes structural changes in the brain which ultimately may drive compulsive use despite negative consequences that characterizes addiction. Other individual-level factors, such as poor self-esteem, low assertiveness and poor-behavioral self control put teens at risk. Co-existing mental health disorders such as, conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, anxiety, post-traumatic stress disorder (PTSD) and history of trauma also put an individual at more risk.2,13 The link between trauma and substance abuse is significant, as research indicates that up to 59% of adolescents with PTSD develop substance use problems.13 Family factors that contribute to substance abuse include direct modeling of substance abuse behaviors and positive attitudes regarding use by household members.1 It is estimated that about 46% of children under 18 (34.4 million) live with a risky substance abuser. The home and family is the most common source of addictive substances after friends.8 Factors within the family that can further contribute to substance abuse include harsh disciplinary practices, poor parental monitoring, low levels of family bonding, and high levels of family conflict.
Screening and Assessment Current guidelines recommend annual screening at every primary care visit.1 Studies show that sick visits and other non-well-child care have higher screen-positive rates than well-child care visits and screening should occur at any visit whenever possible.4 If an adolescent is presenting at an urgent or follow-up visit, he/she is more likely to report alcohol and drug use. Also, it is important to screen teens with a history of misuse of controlled medications as they are more likely to screen positive for substance abuse.14 Research indicates that among adolescents who indicate past-year misuse of controlled prescription medications, 36% have developed at least one symptom of a substance use disorder.15 Possible barriers that have been identified to substance abuse screening Northeast Florida Medicine Vol. 63, No. 1 2012 23
Domestic Violence Update Background - Benefits that Matter!
The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs. One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education (CME) opportunities in the subject areas mandated/and or suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). Helena Karnani, MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator, from SVHC deserve special recognition for their work on behalf of DCMS. This issue of Northeast Florida Medicine includes an article, “Domestic Violence Update” authored by Nancy Motherway, LCSW; Margaret Ghee, LMHC and Raymond M. Pomm, MD (see Insert pp. 3-8), which has been approved for 2.0 AMA PRA Category 1 credit(s).™ For a full description of CME requirements for Florida physicians (MD/DO), please visit the DCMS website (http://www. dcmsonline.org/cme_requirements.aspx).
Faculty/Credentials: Nancy Motherway, LCSW, CAP, CPP, is Director of Gateway Community Services, Inc. in Jacksonville, FL.
A Licensed Clinical Social Worker, Ms. Motherway received her MA in Social Work from the University of Florida State Satellite Program and her BS degree from the University of North Florida. Margaret Ghee, M.Ed., LMHC, NBCC, is the Student Intern Coordinator at River Region Human Services, Inc., in Jacksonville, FL. Ms. Ghee received her MA in Mental Health Counseling & Education from the University of North Florida and her BS degree from Syracuse University. Raymond M. Pomm, MD, is the Medical Director for Gateway Community Services
and River Region Human Services. Dr. Pomm received his MD degree from Meharry Medical College in Nashville, TN and did a Psychiatric residency at Pennsylvania State University Collge of Medicine. He has many post residency years as a practicing psychiatrist.
Objectives for CME Journal Article 1. Define and describe the prevalence of domestic violence within the patient population, including contributing factors and those long-term effects 2. Become aware of simple screening tools to identify domestic violence 3. Learn the questions needed to facilitate assessing the severity of this issue within the patient’s life 4. Learn appropriate interventions and community resources to reduce the risks related to domestic violence
Date of Release: March 7, 2012 Date Credit Expires: March 7, 2014. Estimated time to complete: 1 hr.
Methods of Physician Participation in the Learning Process 1. Read the “Domestic Violence Update” article Insert pages 3-8 2. Complete the Post Test and Evaluation on Insert page 2 3. Members or non-members may fax the Post Test to DCMS (FAX) 904-353-5848 OR members can also go to www.dcmsonline.org & submit the test online. Non-members must arrange for the CME fee payment before submitting the post test by fax. Call 904-355-6561 x106 or fax.
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 and non-members have two years to submit the post test and earn CME credit. A certificate of credit/completion will be emailed or USPS mailed within 4-6 weeks of submission. If you have any questions, please contact the DCMS at 355-6561, ext. 103, or email@example.com.
Faculty Disclosure Information
Ms. Motherway, Ms. Ghee and Dr. Pomm report no significant relationships to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.
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.
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 through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians.The St. Vincent’s Healthcare designates this educational activity for a maximum of 2.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.
Northeast Florida Medicine
Vol. 62, No. 2 2011
Domestic Violence Update CME Questions & Answers (Circle Correct Answer) /Free-DCMS Members/$50.00 charge non-members*
(Return by March 7, 2014 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org) 1. FDCF defines domestic violence as a pattern of behavior that 6. All are IPV Key Safety Planning Elements for Patients from adults or adolescents use against their intimate partners or the Massachsettes Medical Society Campaign EXCEPT: former partners to establish: a. Financial Stability a. Appropriate boundaries b. Protective Order b. Economic security c. Safety at Home c. Power and control d. Safety at Work d. Closer intimacy e. Other 2. In 2009 the CDC fact sheet on Intimate Partner Violence (IPV) stated the number of women and the number of men 7. The 2011 Florida Statues define “domestic violence” as any assault, aggravated assault, aggravated battery, sexual sexually or physically assaulted year were: assault, sexual battery, stalking, aggravated stalking, a. 1 million women/300,000 men kidnapping, false imprisonment, or any other criminal b. 5 million women/3 million men offense resulting in physical injury or death of one family c. 100,000 women/30,000 men or household member by another family or household d. 5 million women/30,000 men member. 3. Which of the following was NOT a screening tool identified a. True to assess for domestic violence: b. False a. RADAR b. HITS c. WEB d. STAR
4. Which is NOT part of the acronym for RADAR: a. R=remember to ask b. A=Ask indirectly c. D=Document findings d. A=Assess safety e. R=Review options 5.
Once current IPV is indentified through screening, the follow-up action should be: a. Reassure patient all will be okay and not to worry b. Ignore the situation if current medical needs are not related to IPV c. Develop a safety plan with the patient and make referrals where appropriate d. Inform patient as a medical professional you are only here to address medical needs & all other concerns should be addressed by professionals in the social service system.
8. History of broken bones, internal injuries, falls, trouble sleeping, and anxiety are all red flags for domestic violence that professionals are accustomed to seeing, yet it can also cause chronic health conditions like irritable bowel syndrome, eating disorders, back pain, gynecological disorders, STDs and heart disease. a. True b. False 9. IPV long term effects can include PTSD, panic attacks, anxiety, suicide attempts and other symptoms, yet many times physicians misinterpret this “Battered Woman’s Syndrome” as neuroses, irrationalities or exaggerations. a. True b. False 10. HITS DOMESTIC VIOLENCE screening tool is designed to only be used with the female population. a. True b. False
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Domestic Violence Update Nancy Motherway, LCSW; Margaret Ghee, LMHC and Raymond M. Pomm, MD Abstract: This article works to provide an understanding of domestic
violence and intimate partner violence as it presents in medical settings. Medical personnel are often the first people to address issues of domestic violence with a patient. The course will provide a description of the victims and perpetrators and the likely associated risk factors. We will look at the prevalence and legal ramifications. In addition, the long term health impact of domestic violence on a patient is outlined. The reader will also be offered specific intervention tools that can be readily incorporated into a practice setting. Lastly, valuable resources will be identified. It can be a challenge to bring up issues of domestic violence with a patient. Our hope is that this article gives you enough understanding and insight which will allow you to make a significant change in the lives of those that suffer as victims from this unfortunate and, at times, deadly act of violence.
Introduction In Tennessee Williams’ classic play A Street Car Named Desire, Stanley Kowalski is showcased as a sensual, desirable, brutish man who dominates Stella in everyway. He humiliates and puts her down and occasionally he is violent, yet it still feels like a love story the way he desperately screams her name into the New Orleans’ night. Tennessee Williams’ picture of domestic violence is more glamorous and theatrical than the abuse reported by our daily news outlets. A study published, in 1998, in the Journal of the American Medical Association (JAMA) indicated that 37% of the women seeking treatment in emergency rooms reported being a victim of emotional and physical abuse at some point in their lives.1 This is a number that reflects only a subsection of the population of potential victims. It does not take into account current laws and recent law enforcement practices. Nor does it reflect the fact that current reporting on domestic violence incidences’ has increased. Other variables that are not reflected in the current numbers are the “on the ground” conditions of our society and economy. An unstable atmosphere, whether in the home or in the general community can have a magnifying effect on domestic stress and violence. In Florida, during the 2008-2009 fiscal year, the Florida Department of Children and Families (FDCF) documented that there were 115,976 cases of domestic violence reported. This was a 2.5% increase over the previous fiscal year. These are sobering numbers and don’t even express the most astonishing facts. In this same report, threat/intimidation, simple assault and aggravated stalking were all increased over the previous year, as well as a 100% increase in domestic violence related homicides.2 Address Correspondence to: Raymond Pomm, MD, Medical Director, River Region Human Services and Gateway Community Services. 390 Park Street, Jacksonville, FL 32204 (River Region). Email: firstname.lastname@example.org. Insert
Defining Domestic Violence The FDCF provides the following definition for domestic violence, “Domestic violence is a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and control. It may include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation and power over one’s partner. Domestic violence knows no boundaries. It occurs in intimate relationships, regardless of race, religion, culture, or socioeconomic status.”2 The 2011 Florida Statues say, “Domestic violence means any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.” In addition, “Family or household member means spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family or who have resided together in the past as if a family, and persons who are parents of a child in common regardless of whether they have been married. With the exception of persons who have a child in common, the family or household members must be currently residing or have in the past resided together in the same single dwelling unit.”3 In both definitions it can be seen that all that needs to be present is a relationship with emotional ties or intimacy, past or present. Sometimes the term “Intimate Partner Violence” (IPV) is used to better describe nuances of the relationship. Domestic violence can have adolescent or adult victims and perpetrators from every socio-economic class, ethnic group or sub culture, and every religious affiliation.4 As long as one individual can maintain and foster power and control over someone they know well, there can be domestic violence. It is important to be aware that domestic violence does not have to only be one person “laying hands” on another. As a physician you may not always see obvious physical signs of domestic violence. Often domestic violence can be categorized in to three areas: physical, emotional and/or sexual. A Jacksonville, Florida shelter for domestic violence identifies economic abuse as a fourth category.5 If we understand that domestic violence is about power and control, then if someone is not allowing your patients to work, controlling their accounts, limiting their access to money, reducing their resources, or neglecting your patients’ needs while using money to meet their own needs, these actions also fit into the definition. Northeast Florida Medicine
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The Faces of Domestic Violence In the office setting, domestic violence is hard to ascertain. More often than not the patient that is a victim of physical abuse is a woman.1,6,7 Interestingly though, a man is more often the victim of psychological abuse.7 There is evidence that heavy alcohol and substance use including prescription drug abuse, as well as, chronic and persistent mental illness, particularly depression and personality disorders, are contributing factors to the existence of domestic violence.1,7,10,11 Additionally, poor social skills, lower education, poverty, pregnancy, disabilities, conflict and anger, limited access to resources in the community, witnessing violence in the home, old age, and young age are all identified as significant risk factors to domestic violence.5,10,11,12 So although not exclusively, your patients who are experiencing domestic violence are often women and children. In 2009 the CDC fact sheet on Intimate Partner Violence (IPV) stated that close to 5 million women are sexually or physically assaulted each year. The incidence for men is in the range of 3 million.6 Male patients can become victims as well. This is especially true if they are elderly, disabled or otherwise identified as vulnerable.8 Unfortunately, we are often talking about your male patients as the perpetrators. A Department of Justice study reported in 2007 that only 3% of the individuals who experience IPV from 1976 through 2005 stated that the perpetrator was a woman.9 It is impossible to tell for certain who is going to commit domestic violence and who is not, but there are some signs to pay attention to. As indicated earlier, the numbers related to incidences of domestic violence are increasing in a parallel fashion to our declining economy. As anxiety related to money, jobs, mortgages and community resources grows, so do the physical and psychological concerns in our general population. Placed in this environment, a person who is unemployed, has reduced coping skills to handle stress, uses and/or abuses mood altering substances (including prescriptions and Over the Counter or OTC), has a belief in strict traditional gender roles, has witnessed violence in family of origin, and is domineering and desires control.10,11,12 Even this information has to be tempered with the fact that, like the victims, the perpetrators can be from any socioeconomic class, religion, race, location or walks of life.12
Health Impacts of Domestic Violence
Once you have an understanding of which of your patients might be victims, it can be challenging to identify how the manifestations and effects of long-term abuse influence patients’ health. From the clinical perspective, emotional and sexual abuse are by far the most devastating to a person and leave the deepest scars, but it is the physical symptoms that will most often get the attention of professionals. History of 4 Vol. 62, No. 2 2011
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broken bones, internal injuries, “falls”, trouble sleeping, and anxiety are all red flags for domestic violence that professionals are accustomed to seeing. Recent studies have related domestic violence to a laundry list of chronic health conditions including irritable bowel syndrome, eating disorders, back pain, gynecological disorders, STDs and heart disease.7,10 On the psychological side, long-term effects can include Post Traumatic Stress Disorder (PTSD), panic attacks, anxiety, somatic concerns, depression, dysphoria, social isolation and suicide attempts.2,10,12 Taken all together, these symptoms can be evidence of “Battered Woman’s Syndrome” yet many times physicians misinterpret them as neuroses, irrationalities or exaggerations.12 Aside from the correlations with chronic and acute medical concerns that clearly affect how you develop your treatment protocol, there is the doctor-patient relationship that has to be considered. Persons in the medical field are trusted experts to their patients. Their patients “bare all”. It has been noted that patients experiencing domestic violence are likely to talk to their medical professional about what is happening if initiated by the professional, yet only 10% of primary physicians routinely ask about it.4 Additional reasons for medical personnel to get involved are the laws related to being a Mandatory Reporter for children and vulnerable adults with regard to abuse, neglect or exploitation. Florida statute 415.1034 outlines the law related to the responsibility of a large variety of professionals, including medical professionals, to report domestic violence.13
Domestic Violence Screening Tools Due to domestic violence being a recurring, chronic condition, routine screening is critical. By identifying patients experiencing domestic violence, interventions could improve a patient’s health and quality of life and, in some situations, it can save a life. Because of scheduling constraints in providing patient care, it is important to utilize time efficiently. Having effective tools that best identify victims of domestic violence and providing intervention and referrals where appropriate can be very helpful. Health issues resulting from domestic violence are too significant to overlook an underlying cause. Three quick and effective domestic violence screening tools are presented here that can be utilized in health care settings. These include RADAR, HITS, and WEB. RADAR is brief Intimate Partner Violence intervention model. It is available online as a pocket resource guide for physicians.14 Its elements include:
R = Remember to Ask A = Ask Directly D = Document findings A = Assess Safety R = Review options Insert
Table 1 HITS Tool for Intimate Partner Violence Screening Please read each of the following activities and fill in circle that best indicates the frequency with which your partner acts in the way depicted. How often does your partner? Never Rarely Sometimes Fairly Often Frequently 1. Physically hurt you
2. Insult or talk down to you
3. Threaten you with harm
4. Scream or curse at you.
Each item is scored from 1-5. Thus, scores for this inventory range from 4-20. A score of greater than 10 is considered positive. Source: Clinical Research and Methods. Fam Med 1998; 30(7);508-12.
The first step of this model is to ask all patients if a partner has ever physically harmed or frightened them. It is important to ask about violence in a confidential setting with only the patient present.14 In step two, an affirmative response should result in asking more specific questions in order to assess the severity of the situation. It has been shown that asking three specific questions, like the following, identified two-thirds of those experiencing Intimate Partner Violence.15 The questions are: 1) “Have you been hit, kicked, punched or otherwise hurt by someone in the past year?” 2) “Do you feel safe in your current situation?” and 3) “Is there a partner from a previous relationship who is making you feel unsafe now?” In the third and fourth step, the information needs to be documented and an assessment of the patient’s current level of safety is critical. It is important to ask questions that determine the immediate risk for danger and whether a referral to a domestic violence shelter is warranted. Developing a safety plan in the fifth step identifies alternatives to the violent situation and is an essential prevention technique. It is important to be aware of key points when asking questions with this patient population. First, don’t ask what the patient did to cause the violence. Frame your questions sympathetically; explaining that no one deserves to be harmed. Compliment the patient on having the courage to discuss the abuse with someone outside the home.16 Inform the patient that all forms of violence are wrong and many are illegal. Do not ask why the patient returns to the violent relationship or criticize the patient for this choice. Instead, ask the patient what he/she can do to increase safety and reduce the risk of violence. Inform the patient that resources are available. Ask the patient what he/she could do to make their environment safer. Offer options that the patient could chose, including referrals. Encourage the patient to feel empowered and to develop a plan that is supportive of their safety as well as their physical and mental health.14 Insert
The patient’s right to self-determination needs to be adhered to; thereby, allowing the patient to make his/her own decision, whether or not you agree with the patient’s choice. This was validated in a qualitative study of battered women who identified qualities in their physician that would support their willingness to confide in them.17 These include listening to the patient in a nonjudgmental approach, valuing the patient as worthwhile human being, and validating that the violence is unlawful and wrong. Another study noted that having someone to confide in and informing them about the abuse reduced the incidents of abuse over a 3-month period.18 There are many screening tools available that can be used in conjunction with the RADAR model. The “Hurt, Insulted, Threatened, Screamed at Scale” (HITS) and “Women’s Experience with Battering Scale”(WEB), have displayed fair to good internal consistency in health care settings with relatively simple ease of use. In one study by Nelson et al, the HITS tool was administered to 259 women in family practice clinics and demonstrated fair internal consistency (Cronbach statistic = 0.80).19 The WEB Scale displayed good internal consistency in two different settings, displaying the ability to differentiate battered women from those who did not experience domestic violence (Cronbach statistic=0.99 and 0.95 in another sample).20,21 HITS is a simple and quick tool to identify victims of domestic violence from both the male and female general patient population.20 It includes 4 questions and rates the range of severity for each question listed. (Table 1) It has been tested in family practice settings with the conclusion that it showed good construct validity in providing the differentiation between patients experiencing domestic violence and those that are not.23 The HITS has also been shown to be effective with males. It is written in gender-neutral terms focused on IPV, allowing it to be used for all adults as part of routine exams. Additionally, new innovations for this tool are being created for easier access and use. Dr. K. Sherin noted in a Northeast Florida Medicine
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November 6, 2011 personal conversation that, “An IPhone or Droid app version may be available soon for free download provided by some community partners and will be called R 3.” A longer, but relatively easy to administer, screening tool is the WEB. It is a 10-question domestic violence screening tool using a six-point Likert scale. This tool measures characteristics of domestic violence related to a woman’s perception of the power and control differential within the relationship and her risk for harm. This tool allows for the professional to ask less threatening questions that are not directly focused on acts of physical violence, yet still provides insight into the risk of abuse that may be occurring within the relationship. The WEB is female gender specific and would be a good tool to use in annual exams with women. It could be easily implemented in written form as the patient waits for her appointment. Clinic staff could score the results identifying at risk patients for further intervention and referral. According to the WEB screening tool, scores of 20 or higher indicate battering.4 One study showed that higher scores were strong indicators of domestic violence. It also indicated that psychological abuse tends to precede physical abuse and could be used as a predictor of physical assaults. Clinical indications are that early screening and intervention of psychological abuse within a relationship may prevent physical abuse.24 However, even though this screen was tested with good accuracy and has been recommended by other professionals, caution must be made in regards to assuming a positive score equals battering. Using this tool, 7% in a large cross-sectional survey of women (n=1152) were falsely identified as victims of abuse.4 Therefore, when a positive score is obtained on this or any domestic violence screening tool, it is important to follow up with further questions to explore the seriousness of the patient’s situation.
Intervention and Referral Interventions are necessary to reduce the risks of domestic violence reoccurring in the patient’s life. Developing a safety plan is a critical intervention in preventing domestic violence. It empowers the victim by providing alternatives to the current situation and a plan that can be implemented if the threat of violence presents itself. Because the most dangerous point for a patient is when they decide to terminate the relationship, developing a safety plan in advance is even more important. In regards to IPV, the Massachusetts Medical Society’s (MMS) Campaign Against Violence (2004) developed “Key Safety Planning Elements for Patients”.14 These include: 1) Emergency, 2) Protective Order, 3) Safety at Home, 4) Safety At Work and 5) Other. According to MMS, it is important to contact police first if there is an imminent threat of harm and have the patient plan a quick departure if necessary. Encourage the patient to obtain a civil protective order and to keep the protective order on her/his person at all times. It is recommended the patient keep a copy in a secure location and contact police 6 Vol. 62, No. 2 2011
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for all violations of the order. Having a civil protective order will reduce incidents of domestic violence as shown in one study (risk ratio in 12 months, 0.2; 95% confidence level, 0.1-0.8.)25 After getting the civil protective order, the patient and the children residing in the home need to keep windows and doors locked at all times. The patient could educate neighbors regarding the dangers of the situation, ask for support and contact the police if needed. The patient should consider removing weapons and dangerous objects from the home. It is important to have protective orders extended to the work place and to inform supervisors and co-workers of this order. The patient could request that their employer report to the patient any incidents of concern related to this order as an added safety measure. It is suggested that the patient place a copy of important documents (birth certificates, social security cards, insurance documents, keys, money, etc.) with someone outside the home. If the patient must leave the abusive situation, the patient should go to a place that is unfamiliar to the batterer. The patient could also contact a domestic violence hotline or shelter. If the perpetrator is not living at the residence and children are involved, educate the patient on the importance of informing the daycare and school of the dangerous situation and who can and cannot access the children. Encourage the patient to teach his/her children how to make collect calls on phones and how to respond in case abduction occurs. Recommend informing the neighbors that the perpetrator no longer lives at the residence and to call 911 if the perpetrator is seen at the home. Suggest developing a code that would inform others of imminent dangers for additional support. Encourage utilization of Employee Assistance Program (EAP) services.26 Referring a patient to a domestic violence hotline is a first step in assisting the patient in developing needed resources. The Florida Domestic Violence Hotline will refer a patient to his or her local domestic violence center. A list of Florida certified domestic violence centers are located at http://bit. ly/xHN26n.27 In cases of elder abuse, refer the patient to the National Center on Elder Abuse’s Elder Care Locator. For suspected incidents of child abuse and/or neglect, contact the Florida Department of Children and Families Abuse Hotline. When calling this hotline, a professional will collect pertinent information and assess if it meets statutory criteria for the Department of Children and Families to conduct an investigation. Reporting suspected abuse or neglect is mandatory for all medical professionals.28 In addition victims of sexual violence can be referred to the Rape Crisis Hotline. (see list below)
1. Florida Domestic Violence Hotline at 1-800-500-1119 2. National Domestic Violence Hotline at 1-800-799- SAFE 3. National Center on Elder Abuse’s Elder Care Locator at 1-800-667-1116 4. Florida Abuse Hotline at 1-800-96ABUSE (1-800-9622873) 5. Rape Crisis Hotline at 1-888-956-RAPE.
Providing a patient with referral information can empower the patient to take the necessary steps to ensure safety and enhance his or her support. Referrals to community resources can assist in targeting specific substance abuse or mental health issues that may be associated with the abuse. Community resources can include substance abuse and mental health treatment providers, Alcoholic Anonymous (www.aa.org/), Narcotic Anonymous (www.na.org/), Al-Anon or Alateen (http://www.al-anon.alateen.org/), Jacksonville Alliance for the Mentally Ill (http://jacksonville.nami.org/), and school guidance counseling. In addition, the Florida Counsel Against Sexual Violence’s website (http://www.fcasv.org/about-fcasv) provides access to local rape crisis centers for those who are victims of sexual violence. Many of these centers provide free services including but not limited to information and referral, crisis intervention, and advocacy and accompaniment.29 Perpetrators of domestic violence can be referred to batterer counseling or anger management programs as well substance abuse and mental health services if these are contributing factors to the abuse. In addition, providing the patient information on local shelters, social services programs, and other community resources empowers the patient to take the necessary steps to ensure safety and enhance his or her support. Perpetrators can be referred to batterer counseling or anger management programs as well substance abuse and mental health services if these are contributing factors to the abuse.
Conclusion The media tells us there is a “health care crisis” in America. In some cases this is referring to the ever-rising costs associated with health care implementation and the difficulty citizens are having accessing quality medical attention. In other cases, we are talking about increasing chronic health concerns within our population like heart disease, diabetes and obesity. Regardless, domestic violence is influenced by both problems. It exacerbates or is the leading cause of many health and mental health conditions and it is often under treated. However, it is important to note that in Florida from 1992 to 2010 the trend has been improving with the overall numbers of reported domestic violence cases decreasing. There was an increase noted in 2005 and another one in 2009.6 It appears that our education, intervention and prevention efforts have been making a difference, but it is tenuous and requires constant attention. It is important that our health care system takes a systemic view of domestic violence and begins to treat the cycle of reoccurrence that happens in families (another system), as well as in the primary relationship. With the trusting relationship of a medical professional and patient, that cycle can begin to change.4 It can all start with a simple set of questions and a dramatic effect can occur. Throughout this writing we have tried to explain that Domestic Violence is something that is pervasive and real in Insert
your practices. Whether your setting is the emergency room, the community clinic or the private office, your patients may experience abuse in a variety of ways from intimates in their lives. Sometimes it is hard to differentiate between the victim and the perpetrator in the case of adolescent child violence on parent or female abuse on a male partner. If you don’t ask, you will never know. 1.
Dearwater S R, Coben J H, Campbell J C, Nah G, Glass N, McLoughlin E, Bekemeier B. Prevalence of intimate partner abuse in women treated at community hospital community departments. JAMA. 1998 Aug 5;280 (5): 433-438. Florida Department of Children and Families (FDCF). (2009). Domestic Violence Annual Report 2008-2009. http://www. dcf.state.fl.us/programs/domesticviolence/publications/docs/ DVAnnualReport0809.pdf Accessed November 7, 2011.
The 2011 Florida Statues. http://www.leg.state.fl.us/statues/ index.cfm?mode=Display_Statute&Search_ String=domesti c+violence&URL=0700-0799/0741/Sections/0741.30.html. Accessed November 11, 2011.
Punukollu M. (2003). Domestic Violence: Screening Made Practical. July 2003. Journal of Family Practice.2(7), 537-543.
Domestic Violence/ Hubbard House. http://hubbardhouse. org/domesticviolence/. Accessed November 10, 2011.
Florida Department of Law Enforcement (FDLE). (2011). Florida Crime Trends – Domestic Violence. Domestic Violence Offenses in Florida, 1992-2010. http://www.fdle.state.fl.us/ content/FSAC/Crime-Trends/Domestic-Violence.aspx. Accessed November 21, 2011.
Coker A L, Davis K E, Arias I, Desai S, Sanderson M, Brandt H M, Smith PH. Physical and Mental Health Affects of Intimate Partner Violence for Men and Women, American Journal of Preventative Medicine.24(4), 260-268.
Centers for Disease Control and Prevention (CDC).(2010). Elder Maltreatment: Definition. http://www.cdc.gov/ ViolencePrevention/eldermaltreatment/definitions.html. Accessed November 8, 2011.
Catalano S. (2007). U.S. Department of Justice: Bureau of Justice Statistics. Intimate Partner Violence in the United States. http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&lid=1000. Accessed December 1, 2011.
10. 10-Centers for Disease Control and Prevention (CDC). (2009b). Intimate partner violence: Fact sheet. http://www. cdc.gove/violenceprevention. Accessed November 23, 2011. 11. 11-Florida Coalition Against Domestic Violence (FCADV), Primary Prevention Toolkit. http://www.fcadv.org/projectsprograms/primary-prevention-toolkit. Accessed November 11, 2011. 12. 12-Florida Department of Law Enforcement. Florida Domestic Violence Fatality Review Team 2008 Annual Report: Executive Summary. http://www.dcf.state.fl.us/programs/ domesticiolence/publications/ doc%5CFatalityReview2008. pdf. Accessed November 23, 2011. 13. The 2011 Florida Statutes: http://www.leg.state.fl.us/statutes/ index.cfm?mode= View%20Statutes&SubMenu=1&App_ mode=Display_Statute&Search_String=415.1034&U RL=0400-0499/0415/Sections/0415.1034.html. Accessed November 29, 2011. 14. Massachusetts’s Medical Society (MMS). (2004). Campaign Against Violence: Pocket Resource Guide for Physicians.http://www.massmed.org/AM/ Template.cfm?Section=Search8§ion= Public_ Northeast Florida Medicine
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Health_Resources2&template=/CM/ContentDisplay. cfm&ContentFileID=493. Accessed November 6, 2011. 15. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA. 1997; 277:1357-61. 16. Huffman JL; Intimate Partner Violence Update. Northeast Florida Medicine. 2007; 58(4):33- 36. 17. Nicholaidis C. the voices of survivors’ documentary. Using patient narrative to educate physicians about domestic violence. J Gen Intern Med. 2002; 17:117-124. 18. Straus HE, Rydman RJ, Roberts RR, et al. A three months prospective outcomes study of recently abused women. Acad Emerg Med. 2001; 8(5); 461. 19. Nelson H., Nygren P., Mclnerney Y., Klein J. Screening Women and Elderly Adults for Family and Intimate Partner Violence: A Review of the Evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2004; 140 (5); 387-396. 20. Smith M, Martin F. Domestic Violence: recognition, intervention, and prevention. Medsurg Nurs. 1995; 4:21-5. [PMID: 7874217. 21. Coker, A.L., Pope, B.O., Smith, P.H. and Hussey, J.R. (2001). Assessment of clinical partner violence screening tools. Journal of the American Medical Women’s Association. Winter: 19-23. 22. Shakil A., Donald S., Sinacore, J., Krepcho, M. Validateion of the HITS domestic violence Screening Tools with Males. Fam. Med. 2005;37(3):193-198. 23. Sherin K.M., Sinacore JM, Li XQ, Zitter Re, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam. Med. 1998;30(7): 508-12.
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24. Croker A.L, Flerx V. C., Smith P.H., Whitaker D.J., Fadden M.K. & Williams M. Intimate partner violence incident and continuation in a primary care screening program. American Journal of Epidemiology. 2007; 165(7): 821-827. 25. Holt VL, Kernic MA, Lumley T, Wolf Me, Rivara FP.Civil protection orders and risk of subsequent police reported violence. JAMA. 2022; 288:589-594. 26. McFarlane J, Parker B & Cross B. (2001). Abuse during pregnancy: A protocol for Preventing and Intervention. and Ed. March of Dimes, nursing module. March of Dimes Fulfillment Center. PO Box 1657, Wilkes-Barnes PA 18773. Website: www.modimes.org. 27. Florida Department of Children and Families (FDCF). (2009). Certified Domestic Violence Centers. http://www. dcf.state.fl.us/programs/domesticviolence/lawsrulescenters/ docs/dvcenters.pdf. Accessed January 11, 2012. 28. Florida Department of Children and Families: Abuse Hotline. http://www.dcf.state.fl.us/programs /abuse/ Florida Department of Children and Families: Florida Abuse Hotline. Accessed November 30, 2011. 29. FCSAV: Florida Council Against Sexual Violence. http://www. fcasv.org/about-fcasv. Accessed January 10, 2012.
Web Illustration for this Article A complete list of “Certified Domestic Violence Centers” is not published in the journal's print version. Please go to dcmsonline. org, click the journal cover and the complete article with the list will be included in the pdf.
by the primary care or any other provider include insufficient time, lack of training in how to manage a positive screen, the need to triage competing medical problems, lack of treatment resources, tenacious parents who won’t leave the room, and lack of familiarity with appropriate, effective screening tools. Given the implications of not identifying substance use, it is important for physicians to strategize to minimize these barriers to routine screening.9 Clinicians should begin asking questions about substance use as soon as the patient is old enough to be interviewed without the parent present, often as early as age 10.1 It is important that the clinician review confidentiality while the parent and child are together to reassure the patient that the details discussed will remain confidential unless there are safety concerns.1 Early identification of risk factors and screening can predict the likelihood of a substance use disorder. In one study of 560 children ages 10 to 12, subjects were identified as high risk if they had two parents with substance use disorders, any tobacco or alcohol use by age 12, and high psychological dysregulation (impulsive behavior, inattention, and negative affect). By the time those subjects identified as high risk reached age 18, three-quarters were using alcohol daily, over one-half had alcohol problems, and nearly one-half had defined cannabis abuse or dependence.16 The HEADSS acronym is a guide for the psychosocial interview for adolescents that ask about home, education, activities, drug and alcohol use, sexuality, and suicide.1, 17 HEADSS is a recommended approach that allows the clinician to develop rapport with the adolescent prior to asking more personal questions. When inquiring about drugs and alcohol, the interviewer should ask three straightforward questions: (1) “Have you ever drunk alcohol (more than a few sips)?” (2) “Have you ever smoked marijuana?” (3) “Have you ever used anything else to get high, including illicit drugs (like cocaine), medications that were not prescribed to you or used in a way other than ordered by a doctor, over the counter medications or inhalant chemicals?” Any adolescent who reports having used alcohol or drugs should be screened with an appropriate screening tool.1 There are a number of screening tools which have been developed which physicians may find useful. Using adult alcohol or drug screening instruments like CAGE is not recommended because they are not developmentally appropriate.18 In addition to helping medical providers identify the presence of a substance use disorder, structured screening devices help clinicians more accurately estimate the severity of substance use.19 The recommended CRAFFT questionnaire is a brief, developmentally appropriate, reliable tool for adolescent substance abuse screening for the clinician (Table 3). It is practical for use in busy, medical outpatient settings. It is a series of six questions developed to screen adolescents for alcohol and drug use disorders simultaneously. Each “yes” response is scored 1 point. A score of 2 or higher is a positive screen that indicates the adolescent is at high risk of having a substance use disorder. A higher CRAFFT score indicates a more severe diagnostic classification. A score of 4 or higher should raise concern of substance dependence.20 24 Vol. 63, No. 1 2012 Northeast Florida Medicine
Table 3 CRAFFT Questionnaire: Screening Test for Adolescent Substance Abuse C Have you ever ridden in a CAR driven by someone (including yourself ) who was “high” or had been using alcohol or other drugs? R
Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are by yourself, ALONE? F
Do you ever FORGET things you did while using alcohol or drugs?
Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into TROUBLE while you were using alcohol or drugs?
NOTE: Two or more “yes” answers is a positive screen indicative of high risk of presence of a substance use disorder and need for further assessment.
It is recommended that all adolescents that have indicated they have used alcohol or another drug should complete the CRAFFT questionnaire or another screening tool because research shows that clinicians often underestimate substance use. In one large study of 2,133 participants, approximately 15% of 12 to 18-year-old patients screened positive in routine outpatient care.4 Of these, 43.5 % reported lifetime use of alcohol or other drugs and 24.1% reported impaired driving risk (positive response to the “CAR” item in CRAFFT).4 Some screen specific strategies can be utilized by the clinician depending on their result. If adolescents indicate that they have not used alcohol or drugs, they should be praised and encouraged to continue to make good choices when it comes to alcohol and drugs. Furthermore, rapport should be established with these adolescents by acknowledging their abstinence and they should be encouraged to discuss any use of alcohol or drugs in the future. An additional important question to ask adolescents who indicate abstinence is if they have ever ridden in a car with a driver who was high or had used alcohol or drugs. If the answer is “yes”, it is recommended they should take part in risk reduction through completing a “contract for life,” a document developed by Students Against Destructive Decisions (SADD). This contract asks the adolescent to never ride with anyone who has been drinking or using drugs or who appears to be intoxicated and calls for parents to promise to provide transportation without questions if their child is in need.1 If CRAFFT is utilized, a screen score of 0-1 lends an opportunity for the clinician to give brief intervention for the Continued to p. 25 www . DCMS online . org
Continued from p. 24
adolescent who has started using alcohol or drugs. Such brief intervention should include advice on stopping alcohol or other drug use and education on the effects of substance use on their health.17 Anticipatory guidance in the form of brief supportive statements can be high yield for curtailing behaviors that lead to a substance use disorder. Clinicians should frame supportive statements relative to knowledge of the patient’s health concerns. For example, athletes using marijuana could be told about the specific effects of marijuana on the lungs to dissuade use. An example of an effective brief statement is “Marijuana use can slowly get you into trouble with your parents, at school, or even with police.” A positive screen CRAFFT score of 2 or above indicates high risk of presence of a substance use disorder and a need for further assessment.17 An assessment begins with open ended questions that should be utilized to gather information to determine the current stage of substance use and appropriate referral and/or treatment. An intervention technique that is important to utilize when assessing positive screened adolescents is motivational interviewing to encourage future behaviors that will result in positive change.17 A thorough alcohol and drug use history should be taken detailing substance use patterns and consequences of use on school performance, social and psychological functioning. Information about the pattern of drug use should include quantity, frequency, peer attitudes towards using, attempts at discontinuing drug use and if attempts have been successful.1 It is important when conducting the history that the clinician attempt to link consequences of use to the adolescent’s use of alcohol and drugs. At this stage it is critical to evaluate the adolescent for co-existing mental illness and a family history for mental health and substance abuse disorders should be obtained.2 If warranted, a physical exam should be performed along with laboratory testing. The exam may reveal signs associated with acute intoxication, withdrawal, or evidence of intravenous use.1 Urine drug screening can be a useful part of the assessment and should be used in context of the entire evaluation as a single negative test does not prove that a teenager is not using drugs and a single positive test does not indicate a substance use disorder.1 Toxicology screening is more likely to be positive and a useful adjunct to evaluation in an urgent or emergency care presentation.21
Staging and Designating Appropriate Treatment Once the information is gathered from appropriate interviewing, the adolescent’s substance use can be categorized to facilitate appropriate treatment (Table 4, p.26). Nonproblematic use is defined as repeated use in social situations for recreational purposes only without associated problems. Appropriate intervention for the patient in this stage is brief advice on stopping use to avoid health consequences and progression to problem use. Studies have shown that brief advice statements are effective in reducing substance use.1, 4 Problem use is defined as use of substances for other than recreational www . DCMS online . org
purposes such as improves mood or use associated with a single problem like school suspension. For adolescents in this stage, targeted brief intervention aimed at reducing substance use and related harm should be initiated. Such appropriate intervention should include individual counseling sessions with a mental health professional such as a psychologist or social worker.1, 4 The referring clinician should follow up after the intervention to determine the patient’s perspective on the intervention and to determine if the adolescent has made a behavior change. If the patient continues to use a substance that is indicative of problem use, referral to a more intensive treatment is appropriate and the clinician should consider involvement of parents in treatment.1 Some adolescents progress into stages of use that are defined as abuse and dependence. Adolescents who meet abuse diagnostic criteria for alcohol or marijuana should be referred for a brief intervention and followed up closely for signs of a behavioral change, and if substance use continues despite intervention, more intensive treatment is required.1 If adolescents are abusing more than one substance, they should be referred to a mental health professional or substance abuse specialty program for a detailed assessment and treatment.1 Some adolescents may demonstrate dependence. Any patient who meets dependence criteria for any substance should be referred to a professional experienced with adolescent addiction.17 Treatment can include outpatient, intensive outpatient, and residential programs.1 When referral is needed, the scope of treatment should be individualized and is dependent on the severity of abuse and co-morbidities. Some patients with dependence may exhibit signs and symptoms of withdrawal.2 Alcohol and benzodiazepine withdrawal may be life-threatening and they should be referred to the nearest emergency room or detoxification unit for medically supervised detoxification.1 It is important for the physician to identify the resources of substance abuse treatment professionals who specialize in addiction medicine so that they are ready to offer the earliest, most effective intervention possible when their patients require it. Earlier intervention by physicians can prevent teens from progressing to more detrimental stages of substance use such as legal complications. According to a CASA analysis, 48.2% of teens were referred to treatment from the criminal justice system while only 4.7% were referred from their health care provider.8
Summary The disease of addiction often has its origins in adolescence. Early recognition and intervention by the physician can prevent or delay continued use of tobacco, alcohol, or other drugs. Adolescent substance use is a public health epidemic and an effective routine screening and intervention strategy should be implemented by all Primary Care Physicians. However, other physicians might be able to contribute significantly by becoming more knowlegable and prepared to deal with such situations as opportunities arise. Additionally, Northeast Florida Medicine Vol. 63, No. 1 2012 25
Table 4 Staging, Description and Intervention/Referral of Substance Use Disorders Stage
Repeated use in social situations, for recreational purposes only, without associated problems.
Brief advice on stopping use to avoid health consequences from primary care physician.
Use for other than recreational purposes or use associated with a single problem.
Referral to counseling sessions with a qualified mental health professional and appropriate follow-up.
See Table 1, DSM-IV-TR Criteria for Substance Abuse
See Table 1, DSM-IV-TR Criteria for Substance Dependence
clinicians should become more knowledgeable about resources in their community for appropriate referral and treatment when warranted.
Ries RK, Fiellin DA, Miller SC et al. Principles of Addiction Medicine Fourth Edition. Philadelphia: Lippincott, 2009.
Griswold KS, Aronoff H, Kernan JB et al. Adolescent substance use and abuse: recognition and management. Am Fam Physician. 2008; 77(3):331-336.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. pp.197-199.
Knight JR, Harris SK, Sherritt L et al. Prevalence of positive substance abuse screen results among adolescent primary care patients. Arch Pediatr Adolesc Med. 2007; 161 (11): 1035-1041.
Johnston Lloyd. “Monitoring the future, 2010”.N.p., n.d. Web.19 Nov 2011. http://monitoringthefuture.org/. Accessed November 20, 2011.
Ruiz P. Substance Abuse: A Comprehensive Textbook, Fifth Edition. Philadelphia, PA. Lippincott, Williams and Wilkins. 2011. pp. 786-788.
Behrendt S, Wittchen HU, Hofler, M et al. Transitions from first substance use to substance use disorders in adolescence: Is early onset associated with a rapid escalation? Drug and Alcohol Dependence. 2009; 99(1-3): 68-78.
Adolescent Substance Use: America’s #1 Public Health Problem. A Report by The National Center on Addiction and Substance Abuse at Columbia University. New York NY. June 29, 2011 (Material taken from a Powerpoint
26 Vol. 63, No. 1 2012 Northeast Florida Medicine
16. 17. 18.
Referral to a mental health specialist or a substance abuse specialty program for detailed assessment and treatment. Outpatient treatment that involves group, individual, and family therapy is often adequate. Referral to a mental health or substance abuse specialist for detailed assessment and treatment, which can range from outpatient to residential programs. If withdrawal is a possibility, referral to a medically supervised detoxification.
presentation. For full report see http://www.casacolumbia. org/upload/2011/20110629adolescentsubstanceuse.pdf ). Van Hook S, Harris SK, Brooks T et al. The “Six T’s”: Barriers to screening teens for substance abuse in primary care. J Adolesc Health. 2007; 40: 456-461. Knight JR, Goodman E, Pulerwitz T et al. Reliabilities of short substance abuse screening tests among adolescent medical patients. Pediatrics. 2000; 105(4): 948-953. Greydanus DE, Patel DR. Substance abuse in adolescents: a complex conundrum for the clinician. Pediatr Clin N Am. 2003; 50: 1179-1223. Belcher HME, Shinitzky HE. Substance abuse in children. Arch Pediatr Adolesc Med. 1998;152:52-960. The National ChildTraumatic Stress Network. Understanding the links between adolescent trauma and substance abuse. A Toolkit for Providers, 2nd Edition. Boston, MA, Coordinating Center for the NCTSN June 2008. p.1. McCabe SE, West BT, Cranford JA et al. Medical misuse of controlled medications among adolescents. Arch Pediatr Adolesc Med. 2011; 165(8): 729-735. Schepis TS, Krishnan-Sarin S. Characterizing adolescent prescription misusers: A population-based study. J Am Acad Child Adolesc Psychiatry. 2008; 47(7): 745-754. Clark, DB, Thatcher DL. Emerging clues: Is this teen at risk for substance abuse? Current Psychiatry. 2009; 8(1): 19-27. Levy SJL, Kokotailo PK. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011; 128(5): 1330-1340. Christie G, Marsh R, Sheridan J et al. The Substances and Choices Scale (SACS) –the development and testing of a new alcohol and other drug screening and outcome measurement instrument for young people. Addiction. 2007; 102: 1390-1398.
www . DCMS online . org
19. Wilson CR, Sherritt L, Gates E et al. Are clinical impressions of adolescent substance use accurate? Pediatrics. 2004; 114(5): 536-540. 20. Knight JR, Sherritt L, Shrier LA et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002; 156: 607-614. 21. Kozer E, Bar-Hamburger R, Rosenfeld N et al. Strategy for increasing detection rates of drug and alcohol abuse in pediatric emergency departments. Acta Paediatrica. 2009; 98: 1637-1640.
Adolescent Substance Use Resources
The National Institute on Drug Abuse NIDA for Teens Web site: http://teens.drugabuse.gov/
• Substance Abuse and Mental Health Services Administration, Tips for Teens. Free alcohol and drug information brochures.Web site: http://store.samhsa.gov/pages/search Result/Tips+for+teens • Substance Abuse and Mental Health Services Administration TIP 31: Screening and Assessing Adolescents for Substance Use Disorders Free publication that discusses assessment, referral and treatment Web site: http://store.samhsa.gov/ product/TIP-31-Screening-and-Assessing- Adolescents-ForSubstance-Use-Disorders/SMA09-4079 • The National Center on Addiction and Substance Abuse at Columbia University Substance Abuse Treatment Facility. Locator from SAMSHA Assistance in finding an appropriate substance treatment center. Web site: http://findtreatment. samhsa.gov/TreatmentLocator/faces/quickSearch.jspx • The American Academy of Pediatrics. Parents Website that has useful articles on substance use in adolescents. Web site: http:// www.healthychildren.org
"Images in Medicine" is a new NEFM Journal website feature. Check it out and submit an image.
• Al-Anon/Alateen. Support group for families and friends of alcoholics and young persons. Website: http://www-al.anon. al-anon.alateen.org
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Methadone Treatment in Pregnancy... That Can't Be Right, Can It? Stacy Seikel, MD Abstract: Methadone, a full μ (mu)-opioid agonist, is the recommended
treatment for opioid addiction during pregnancy. Many medical providers are confused about its use and some perpetuate the stigmatization of this very important treatment for pregnant women who are addicted to opioids. In this article, methadone and Buprenex (Buprenorphine) will be presented as safe and effective treatments for the pregnant addicted patient. Clinical tools such as the Prescription Drug Monitoring Program will be discussed and its utilization reviewed. Also, the use of Point of Care (POC) drug screens will be presented in the context of the physician’s office setting.
Introduction I remember the first day of my “methadone clinic rotation” more than ten years ago. Having left the field of anesthesiology, I had a good fund of knowledge for the use of opiates in treating pain. The thought of using an opiate to treat opiate addiction, just seemed wrong. I was familiar with abstinance based recovery. That’s easy. You get off drugs and you do whatever it takes to stay off drugs, right? “Medication Assisted Recovery” was a new concept for me. I was excited about my new job in a large publicly-funded substance abuse treatment agency. I had worked in detox, worked with substance abusing adolescents in the Department of Juvenile Justice programs, and worked in a men’s residential drug treatment program. Now I was working in the Methadone Clinic, and in my naïve, somewhat arrogant mindset, I thought I would find people just replacing one drug for another. Was I wrong about that!
living on the street. What did I know about working hard for one’s recovery? These patients were teaching me about recovery every day.
Methadone Treatment During Pregnancy
But what about methadone treatment during pregnancy? I remember during this time sarcastically saying to the medical director, “So we are going to expose these developing fetuses to methadone for nine months? Surely we can come up with something better than that!” Again, I had a lot to learn. Methadone is the gold standard of treatment for the opiate addicted pregnant patient.1 It stops craving, is typically dosed once per day, does not create euphoria, and it blocks the effects of short acting opiates due to its high affinity for the mu receptor. This is all backed by more than fifty years of solid clinical research. That sounds good for the mom, but what about the baby? Aren’t drugs bad for babies? It turns out methadone has been used and studied in pregnant women and their babies since the 1950s. Over the decades, experience has shown that pregnant women with opiate dependence/ addiction have much better fetal outcomes than mothers who taper off opiates during pregnancy.2 The reason for this is that the relapse rate is high, and with the relapse, typically comes polysubstance use.
One of my first patients was a woman who was twenty weeks pregnant and was already the single mother of a six year-old girl. This patient walked her daughter to the bus stop to see her off to school every morning. She then caught public transportation with three bus changes to get to the Methadone Clinic; the new politically correct term is now Opiate Treatment Program (OTP). This patient would get her daily dose of methadone at the clinic and then attend either group or individual therapy sessions. She would catch another bus to her job which was cleaning houses and be back in time to greet her daughter at the bus stop after school. She walked her daughter home, helped with homework, fixed dinner, bathed her, and got her to bed. She would then do her assignments from the counseling group, call her sponsor in Narcotics Anonymous, say her prayers, and go to bed. She got up every morning and did the same thing again. She was one of the most grateful and joyful people I had ever met. Eighteen months prior, she had been injecting heroin and
It seems that methadone in pregnancy is the lesser of two evils. A woman can go on methadone maintenance, learn recovery and parenting skills, and have a full term, normal weight, healthy infant. Alternatively, she can taper off the opiates, have a ninety percent chance of relapsing, and expose the fetus to a plethora of illicit drugs. When a fetus is in and out of withdrawal throughout pregnancy, it cannot grow and develop normally because it is in distress. But on a stable dose of methadone in utero, the baby can grow and develop normally because it is not in distress.3 This full-term, normal weight, otherwise healthy newborn will be physically dependent on opiates.4 It is not addicted to opiates. Addiction is characterized by use despite harm, cravings, and pre-occupation. Babies don’t have that; they have physical dependence. Now we have the opiate withdrawal to treat, known as Neonatal Abstinence Syndrome (NAS). This can be handled by early effective intervention, sometimes requiring IV opiates, sometimes not.5 That is better than exposing the fetus throughout pregnancy to drugs.
Address Correspondence to: Stacy Seikel, MD, Medical Director, The Center For Drug Free Living, 3670 Maquire Blvd., Suite 202, Orlando, FL 32803. Email: SSeikel@CFDFL.com.
There is science behind this totally counter-intuitive treatment in the pregnant opiate addict. First of all, what is this disease of addiction? Is it physical dependence, lack of willpower, or a brain disease? According to the American
28 Vol. 63, No. 1 2012 Northeast Florida Medicine
www . DCMS online . org
Society of Addiction Medicine, addiction is “a primary chronic neurobiologic disease, with genetic, psychosocial, and environment factors influencing the development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.” One can remember these criteria as the “Four C’s.” The use of methadone or buprenorphine for the treatment of opiate addiction is called Opioid Agonist Therapy.6 In pregnancy, studies are unclear regarding the relationship between the dose of methadone and the severity of NAS. However, studies are very clear that most patients (pregnant or non-pregnant) relapse if taken off methadone before one year of methadone is completed.7 Sublingual buprenorphine was FDA approved in 2004 for use in opiate addiction. It can be obtained in a private physician’s office, not only at an OTP. Buprenorphine is being used successfully in pregnancy for opiate addicted patients.8 A recent publication in the New England Journal of Medicine compared newborn Neonatal Abstinence Syndrome in methadone or buprenorphine maintained pregnant women.5 The outcomes showed less severe Neonatal Abstinence Syndrome and shorter hospital stays in the babies born to the buprenorphine maintained mothers. Both drugs are designated “Category C” by the FDA. However, Methadone is approved for use in pregnancy by the National Institutes of Health consensus panel. This approval is based on fifty years of successful experience in its use in pregnancy. Methadone remains the gold standard for opiate replacement therapy in the opiate addicted pregnant patient. Every day, pregnant women with opiate addiction come to me wanting to “detox” and get off “everything.” It takes
support and education with the patient and family for them to understand that they are doing the right thing for the baby by going on methadone. They must understand the difference between untreated withdrawal (intrauterine) and treatable withdrawal in the neonate. The patient needs to be constantly reassured that she is putting her infant first and doing the right thing. A team approach of obstetricians, pediatricians, neonatologists, nurses, addictionologist, and primary care providers all giving the patient the same message, that she is doing the right thing by going on methadone, is invaluable.9 It is not difficult for patients to find someone who disagrees and says that these babies are addicted and are harmed by taking Methadone during pregnancy. These statements are not only inaccurate, but they also are harmful. I have many pregnant patients who are stable in their recovery, active in counseling, and engaged in twelve-step recovery who are living a lifestyle that will be healthy and supportive for the newborn. Sometimes these stable successful patients will request to taper while pregnant. When I inquire as to why they are requesting a taper, typically it is due to pressure and guilt from a family member or sometimes even a misinformed medical professional. It is not difficult to induce guilt in these women; they are remorseful and concerned about the well-being of their babies. It is hard to assess the impact of polysubstance use in early pregnancy. However, we know of minimal to no long-term negative sequelae on babies born to mothers who are on stable doses of methadone, engaged in psychosocial services, and in a stable living environment.7
Understanding Addiction As I worked with pregnant women in the Opiate Treatment Program, I came to understand that addiction is a brain disease affecting 10-15% of the general population.9 More importantly, I saw that treatment works. I felt humbled to see this amazing transformation of a woman whose brain was being run by a limbic system in overdrive, to one with intact executive function and a prefrontal cortex that could override a thought of using. By studying Nora Volkow’s work at the National Institution of Drug Addiction (NIDA), I saw evidence that the limbic system had markedly increased activity on PET images.10 The prefrontal cortex in these patients with active addictive disorders had diminished cellular activity.11 In neuroimaging, this is called “hypofrontality.”12 Scientists could predict relapse in cocaine addicts by “how dark,” or the degree of hypofrontality, in these patients.10 Now it made sense. This was a brain disease, not a moral failing. When this information was coupled with Dr. Kreek’s work on the effects of short acting opiates on the mu receptor13, it all came together for me.
Graphic used with permission from the National Institute on Drug Abuse. See www.nida.nih.gov. www . DCMS online . org
When the mu receptor is chronically activated by short acting opiates over a period of time, it results in altered gene expression. Once there is new gene expression, the playing field has changed. With new genes being expressed, new metabolic pathways are activated from new enzymes, and the brain has been changed,1 most likely permanently.9 In Narcotics Anonymous, there are sayings “once an addict, always an addict” and “you can’t change a pickle back into a cucumber.” That now made sense to me. With this information, I understood now why methadone was necessary in early Northeast Florida Medicine Vol. 63, No. 1 2012 29
recovery in order for my patients to learn new coping skills, relapse prevention skills, parenting skills, and the ability to ask for help through an extensive support network. This network started with her counselor and peers in the OTP, but eventually grew to include women in recovery in community-based twelve step programs. So how prevalent are addictive disorders in pregnant women? It appears that the prevalence is about the same as the general population (i.e. 12-25%). There seems to be no difference in socioeconomic status or in the patient being seen in a public clinic versus a private practice.9
I do not know of one patient in active addiction who truly wants to continue being a prisoner to this disease. Instead, the person is hopeless and afraid and often convinced that treatment does not work. The brains of patients who have abused drugs and alcohol often have been altered significantly. Some of these patients need medication in order to engage in treatment and to stabilize. Some will be able to successfully undergo a medically supervised taper after delivery, and some will need to be on medication long term. Methadone is not an evil drug. It is a highly effective medication for the treatment of opiate addiction in pregnancy. I know, because I see it working every day.
Screening for Substance Abuse
Screening pregnant women for substance abuse has become a controversial topic. Opponents are concerned that marginal populations will be targeted and punished instead of getting treatment.14 This is a legitimate concern. I believe that all women should have a drug screen on their first prenatal visit. Physicians need to use that data to engage the patient into treatment services if needed. A punitive, judgmental attitude will scare patients away. Often they will continue their drug use and not continue their prenatal care. There are many questionnaire-based screens that are designed specifically for women. Personally, I believe the best screen is a drug screen. Point of Care (POC) drug screens provide results in 3-5 minutes, on site.15 These tests are inexpensive; a 12 panel test is about $5.00, practical and easy to use. When coupled with a patient query in Florida’s new Prescription Drug Monitoring Program (PDMP), the playing field is leveled between the physician and the patient who may have a substance use disorder. These patient queries are called Patient Advisory Reports (PAR) and can be obtained in less than a minute. Physicians can get a username and password by going to www.E-FORCSE.com. Once credentials have been obtained, go to www.hidinc.com/flpdmp to run a patient query. It only makes sense to know what controlled substances a patient may be taking. Physicians need to remember that the “spirit of the law” is not to incarcerate every person with a substance use disorder. I use this resource as a clinical tool. My office staff obtains a PAR the day before a patient is scheduled to come in and clips the report to the chart. I look for inconsistencies between what the patient is telling me and what the PAR is indicating. I respectfully point out to the patient that it appears that she may have a substance use disorder. I discuss addiction as a brain disease that is responsive to treatment. I then reinforce that I know this pregnant woman wants to be a good mother and does not want to put her unborn child at risk. Pregnant women are the most motivated patient population that I treat.
Conclusion My hope is to diminish the stigmatization of methadone and buprenorphine in Opiate Treatment Programs. In pregnant patients, methadone is the gold standard of treatment. It stops craving, allowing the patient to fully engage in the recovery process. I have heard people say “Oh, she’s just not ready. She’ll stop when it’s bad enough.” That is simply not true. 30 Vol. 63, No. 1 2012 Northeast Florida Medicine
TIP 2: Pregnant, Substance Using Women http://www. nchi.nim.nih.gov/books/hv.fogi?rid=hstat5.chapter.22442 November, 12, 2011.
McCarthy JJ, Leamon MH, Parr MS, Anania B. High dose methadone maintenance in pregnancy: maternal and neonatal outcomes. Am J Obstet Gynecol 2005 Sept; 193(3): Pt (1):606-10.
Dashe JS, Sheffield JS, Oischer Da, et al. Relationship between maternal methadone dosage and neonatal withdrawal. Obstet Gynecol 2002 Dec; 100(6):1244-9.
Jones HE, Jonson RE, Jasinski DR, Milio L. Buprenorphine versus methadone in the treatment of pregnant opioiddependent patients: effects on the neonatal abstinence syndrome. Drug Alcohol Depend 2005 July; 79 (1):1-10.
Jones E, Kaltenbach K, Heil S, et al. Neonatal Abstinence syndrome after Methadone or Buprenorphine Exposure. New England Journal of Medicine; 2010 Dec;363(24):2320-31.
Hulse GK, O’neil G.Methadone and the pregnant user; a matter for careful clinical consideration. Aust NZ Obstet Gynacol, 2001 Aug; 41(3):329-32.
Hulse GK, Milne E, English DR, Holman CD. Assessing the relationship between maternal opiate use and neonatal mortality. Addiction 1998 Jul; 93(7): 1033-42.
Lacroix I, Berrebi A, Chaumerliac C, et al. Buprenorphine in pregnant opioid-dependent women: first results of a prospective study. Addiction 2004: Feb; 99 (2) 209-14.
Wunsch, M., Weaver, M. Alcohol and Other Drug Use During Pregnancy. In: Principles of Addiction Medicine 4th. Ed, ASAM; 2009, Lippincott, Williams & Wilkins; Philadelphia, PA.,Ch. 81:1111-1122.
10. Volkow ND, Hitemann R, Wang GJ, et al. Changes in the brain glucose metabolism in cocaine dependence and withdrawal. Am J Psychiatry 1991;148:621-626. 11. Volkow, ND, Hitzemann R, Wang GJ, et al. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 1992:11:184-190. 12. Volkow ND, Mullani N, Gould KL, et al. Cerebral blood flow in chronic cocaine users: a study with positron emission tomography. Br J Psychiatry 1988;152:641-648. 13. Kreek MJ. Methadone-related opioid agonist pharmacology of heroin addiction. History, recent molecular and neurochemical research and future in mainstream medicine. Ann NY Acad Sci 2000;909:186-216. 14. Foley EM. Drug Screening and Criminal Prosecution of Pregnant women. J Ob Gyn Neonat Nurs 2002; 31(2): 133-137. 15. Swotinsky R. Smith D. Laboratory analysis. In: The Medical Review Officer’s manual: Medical review Officer Certification council. 1999. OEM Press; Beverly Farms, MA. 57-76. www . DCMS online . org
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Northeast Florida Medicine Vol. 63, No. 1 2012 31
Nonpharmacologic Strategies for Treating the Addicted Patient in an Office-Based Setting: Motivational Interviewing Heidi A. Pomm, PhD Abstract: One of the most difficult and frustrating type of patients
physicians encounter are those with substance use disorders. Unfortunately, in the primary care setting, many physicians see several of these “drug-seeking” patients each day. This article presents a brief counseling approach known as “Motivational Interviewing.” Physicians can utilize it to help their addicted patients, assist them in feeling less responsible for their patient’s aberrant behaviors, and increase the physician’s sense of perceived control during these difficult encounters.
Introduction The addicted patient, or “drug seeker,” is no doubt one of the most difficult patients for most physicians. While there is no easy “fix” to this problem, there is a strategy the physician can employ in an office-based setting to help their patients who have substance use disorders. Unfortunately, for most physicians, obstacles such as limited time and lack of training in this area make the implementation of traditional treatments (individual and group psychotherapy, self-control and social skills training, etc) unfeasible. Therefore, this article will focus on one well-known and well-studied brief nonpharmacologic intervention—motivational interviewing---that can be administered by the physician.
Motivational Interviewing Defined Motivational Interviewing (MI) stems from a theoretical construct known as the transtheoretical stages-of-change model.1 The literature attesting to the beneficial effects of MI with problem drinkers2-5, heroin users6, cocaine users7, and polydrug users8 is enormous. In fact, MI strategies are not only helpful for patients with substance abuse disorders: MI techniques can be applied to any behavior the physician believes would be in the best interest of the patient to modify; eating habits, smoking, lack of exercise, and many others. Simply put, a central premise of MI is that individuals move through stages of behavior change; that is, a behavior change does not occur overnight. Unfortunately, in most settings, patients are ordered immediately to stop smoking, drinking, using drugs and so on. However, if change is a dynamic, time-intensive process, and not an immediate event, we can Address Correspondence to: Heidi PhD, former Faculty Member & Coordinator of Behavioral Science, St Vincent’s Family Medicine Residency Program, Jacksonville, FL. Currently with Amelia Psychological Services, Fernandina Beach, FL. 32034 (904) 277-2052 Email: paradocsHP@aol.com.
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see why most physicians feel so frustrated and angry by their patient’s noncompliance; quick results invariably do not occur. So, the bad news is that our patients are unlikely to respond to our admonishments and take to heart our recommendations right away. The good news, though, is by using MI strategies and by conceptualizing our patient’s struggles from a stage perspective, we can help them move through the process more quickly. Equally important is that, by using MI techniques in your practice, you will feel less pressured to “cure” your patients and your patients will feel more in control of their choices. The end result can be a much-improved, and therefore more mutually beneficial and effective, physicianpatient relationship.9 It should be noted that all patients on long-term, controlled substances should have signed a medication agreement with their physician and agree to random urine drug screens. In addition, physicians should also discuss not only the side effects and the potential for tolerance and dependency of certain controlled substances, they should also work with the patient to determine a goal, how they will determine that this goal has been achieved, the projected length of treatment and what will need to occur if the goal has not been achieved. For example, when initiating a trial of a long-acting pain medication for a patient, the goal is to alleviate the majority of the patient’s perceived pain. If the medication has not helped after a determined length of time, the physician should consider changing the medication, or, if pharmacological therapy does not prove to be effective, weaning the patient off the medication entirely. Nonpharmacologic treatment of pain, such as interventional procedures (if appropriate), biofeedback, cognitive-behavioral therapy, physical therapy, hydrotherapy, acupuncture, neuromuscular massage, etc. should always be recommended, whether the patient is on drug therapy or not. If a patient has failed the agreement, or if the physician has concerns about the patient’s safety (i.e. the patient is drinking or “drugging” heavily and is “out of control” and/or is experiencing serious physical complications secondary to their substance use), then the physician must gently confront the patient and require that he/she either go into a detoxification/treatment facility or be referred to a pain management specialist. In very few areas of the country, one, fortunately, being Duval County, there are Board-Certified Anesthesiologists who are also Board-Certified in both Interventional Pain and Addiction Medicine (Dr. William S. Jacobs and Dr. John Hunt at NexStep Integrated Pain Care: 904-288-8311). Many physicians are not comfortable with confrontation. However, addicts will continue using unless they have consequences. Physicians who are worried about the actual safety www . DCMS online . org
of a patient because the patient’s substance use has escalated enough to cause true medical concern, but who do not confront the patient, are participating in a form of enabling (which may have serious consequences for both the patient and the physician). For those patients whom the physician does want to assist, and who are not in grave danger, MI can be a very useful and effective strategy.
Motivational Interviewing Stages The five stages of change proposed by the transtheoretical model are 1) Precontemplation, 2) Contemplation, 3) Preparation (or Determination), 4) Action, and 5) Maintenance. Another stage is often 6) Relapse which, should it happen, also needs to be addressed.10,11These stages are not linear; that is, one does not enter one stage and go directly to the next. Rather, these stages can be conceptualized as a dynamic cycle through which patients move back and forth.10 One of the best questions this author has found to assess exactly where a patient is in the stages of change is to ask him or her the simple question, “How do you think your (drinking, opiate use, benzodiazepine use, etc) is affecting your life?” Precontemplation – In this stage, addicted patients are in denial. In answer to your initial question, they may respond, “Not at all. I can quit whenever I want to.” They minimize or deny that they have a problem. They tend to blame others for their drug use. Strategies such as “You have to stop drinking now!” or “You just need to quit—can’t you see what your drug use is doing to you?” only cause the precontemplator to withdraw. However, the physician can help the Precontemplator move towards Contemplation by utilizing the following strategies: 1) Let your patient know you are concerned and inquire about the patient’s thoughts on the matter; 2) Gently point out discrepancies; 3) Ask your patient to think, talk or read about substance abuse/addiction between visits.11
statements such as, “Doc, you were right. I’ve been on these pain pills for so long and they really aren’t helping me—I really want to stop taking them.” They may experiment with small changes as their determination increases. The physician, or patient, may suggest a “start date” for the cessation of substance use. Strategies the physician can use to help patients at this stage include: 1) Summarize patient’s reasons for change; 2) Negotiate a start date to begin changing the problematic behavior; 3) Encourage the patient to announce his/her plan publicly (to a support group, family or friends) and to attend a 12-Step meeting, such as Alcoholics Anonymous (AA; www. neflaa.org, 904-399-8535) or Narcotics Anonymous (NA; www.firstcoastna.org, 904-723-5683) , as an “experiment”; 4) Arrange a follow-up appointment shortly after start date.11 Action – The action stage is the one physicians are eager to see their patients reach.12 Patients in the Action stage will often respond to your initial question by stating, “I finished my detox and I’m going to treatment and to my 12-Step meetings!”The patient is now following a plan of regular activity to change the problem (i.e., no longer using substances, is involved in 12-Step meetings, etc). However, in this early stage of success, the patient is particularly vulnerable to impulsively returning to problematic behavior. The physician can support patients in the Action stage by: 1) Showing interest in the specifics of the patient’s plan; 2) Help the patient anticipate how to handle a slip or full-blown relapse; 3) Support and re-emphasize the pro’s of changing; 4) Help modify aspects
Contemplation – When patients are in this stage, they are often the most frustrating to the physician. This is because ,while they have begun to recognize they may have a problem (denial has lessened), they still may be unwilling to change their behavior. When asked how their substance use is affecting their lives, these patients might reply, “Well, I know I am drinking a bit too much, but it really isn’t that bad.” They may weigh the pro’s and con’s of continued substance use, but may also become obsessive about the problem, which may prolong this stage. In order to help your patient move towards the Preparation/Determination stage, the physician should: 1) Elicit the patient’s perspective first; 2) Help identify the pros and cons of continued substance use; 3) Ask what would promote commitment; 4) Suggest trials (11), such as using less of the substance (Don’t suggest trials if the patient is physically dependent on the substance since asking the substance-dependent patient to drink less or use less opioids could precipitate withdrawal) Preparation/Determination – In this stage, the patients finally realize that change is needed. In answer to your initial question, these patients may cause you to feel hopeful, making www . DCMS online . org
Graphic used with permission from the National Institute on Drug Abuse. See www.nida.nih.gov. Northeast Florida Medicine Vol. 63, No. 1 2012 33
of the action plan if aspects are not working well; 5) Schedule frequent follow-up appointments for support.11 Maintenance – After about six months in the Action stage, the patient is now in the Maintenance stage. The patient may have realized how much the change has improved his life. However, it is of utmost importance that the patient remains vigilant, as complacency may begin to creep in. In AA and NA, members often remark, “The easiest part of stopping drinking (or using other substances) is stopping; the hardest part is staying stopped.” Your patient should have a 12-Step “sponsor” (another member of the 12-Step program who has already “worked the Steps,” by this time) and should be actively involved in attending 12-Step meetings. If a patient is attempting to stay abstinent without support groups, the risk of relapse can be greater. The physician should ask the patient if he or she is going to 12-Step meetings, if they have a sponsor and if they have any concerns about relapse. If so, ask the patient what can be changed to avoid relapsing. Relapse – A relapse is basically defined as a consistent return to substance abuse. It is not an uncommon occurrence and is often part of the change process. Patients may have “slips” (i.e. return to substance use for a short time), but relapse is a return to the previous full-blown addictive behavior. It is not unusual for a patient who was abusing alcohol to “transfer” their abuse to another substance, such as opioids or benzodiazepines. The patient may return to the Precontemplative stage, especially if he/she is abusing a different substance: “Doc, I know I had a problem with alcohol, but I don’t have a problem with this pain medicine.” If a relapse occurs, the physician may feel angry, betrayed or even inadequate. It is critically important for the physician not to take responsibility for your patient’s perceived failure, but rather view it as a natural, and often inevitable, part of the change process. Many patients who have relapsed feel a tremendous amount of shame, embarrassment, regret and remorse. They may feel they have let you, their physician, down, as well as their family members, friends and co-workers. In the AA Big Book, this overwhelming feeling of self-hatred is termed, “pitiful and incomprehensible demoralization.” Relapsers often feel so beaten down, they certainly do not need their physician to admonish or scold them; they need empathy, support and to be told that they have an illness which is one that can be relapsing and remitting by its chronic nature—just like many other types of chronic illnesses. And, after a relapse, recovery can actually be strengthened. Indeed, in the 12-Step programs, it is believed that relapse can actually serve to, paradoxically; improve recovery from addiction, once the patient returns to the “Action stage”. The physician can help the patient who has relapsed by being empathic and encouraging and by :1) Framing the relapse as a learning opportunity in preparation for the next Action stage; 2) Ask the patient to identify the “triggers” that preceded the relapse (i.e., the patient had stopped going to 12-Step meetings, or had gotten angry or resentful, etc); 3) Remind the patient about his/her reasons for changing 34 Vol. 63, No. 1 2012 Northeast Florida Medicine
in the first place; 4) Use the term “When,” rather than “If,” in describing the next change attempt; Normalize relapse as a common experience on the path to successful long-term change.11 However, patients who continue to relapse multiple times (“chronic relapsers”) should be referred to a substance abuse professional for evaluation of the need for treatment.
Additional Strategies One way to view MI is that it is a “patient-centered,” rather than “doctor-centered” approach. No physician can make her patient change, and the harder the doctor tries to “force” her patient to stop drinking and/or drugging, the more resistant the patient becomes, with the outcome typically being one of frustration and anger for both parties. MI is based on meeting, or accepting, where your patient is in the stages of change. Take a moment and think of a problem behavior you, the reader, has experienced in your life. Perhaps you ate too much carbohydrates, did not exercise enough or worked so many hours that you did not have much time to spend with your family. Perhaps you even drank too heavily or abused other substances (physicians are definitely not immune to addiction! There are thousands, quite possibly, hundreds of thousands--of recovering physicians and other doctoral-level individuals world-wide who not only attend AA meetings, but are also very active in “sub-specialty” recovery groups, such as International Doctors in AA (IDAA: www.idaa.org), and a listserve named “Cyberdocs”). Patients who are in the Precontemplative and Contemplative stages (the latter which may last for years) are, understandably, the most difficult and frustrating types of patients the physician encounters. In addition to the strategies listed in the previous section, there are four principles that guide the practice of MI which may be especially useful for patients who are “stuck” in these two early behavior change stages: 1. Express Empathy : the physician refrains from judging the patient; instead, through allowing the patient to talk while the doctor listens respectfully, the physician adopts and projects an attitude of acceptance of where the patient currently is in the stages of change process. The physician understands that ambivalence is normal and skillful listening is critical 2. Develop Discrepancies: although the physician recognizes that the patient’s ambivalence to change is normal, the physician is not ambivalent about the need for change. The physician helps the patient perceive the discrepancy between the patient’s current behavior and the patient’s personal goals. Once the patient has identified some personal goals (i.e., to have a better relationship with his family, to have better health and so on), the physician may ask, “How would continuing to drink help you achieve those goals?” Ideally, the patient, rather than the physician, should present the arguments for change; “Well, if I continue drinking, I won’t have a better relationship with my family and, from you have already told me, Doc, I sure won’t have better health since drinking is already causing some of my health problems” 3. Roll with Resistance: The physician should avoid arguing www . DCMS online . org
for change. If the patient becomes resistant or defensive, the physician should simply change his strategy by offering new information, or shifting the topic. The least desirable situation, from the standpoint of evoking change, is for the (physician) to advocate for change while the (patient) argues against it. 4. Support Self-Efficacy: Your patient must believe that s/he actually can make a change prior to doing so. The physician should engage the patient in “confidence talk” in which the patient is invited to share “ideas, experiences, and perceptions that are consistent with the ability to change.” The patient’s positive remarks about their ability to change are termed “change talk” and are the opposite of resistance. The physician can aid the patient by encouraging the patient to discuss past successes, communicate to the patient that you believe change is possible, encourage the patient to attend an AA/NA meeting to see others who had the same problem but who were able to change, and by identifying personal strengths (perhaps encourage the patient to make an “affirmation” list of positive attributes either the patient believes he/ she has. If that proves difficult, the physician may ask, “What are some good qualities that other people have identified you have?” The physician can give the patient ‘homework’: “Read your list of affirmations two times a day—whether you believe them fully or not,” to help increase the patient’s sense of self-efficacy.13 Some additional MI strategies that have been found to be the most successful, regardless of what stage the patient is in (but may be especially helpful in the earlier stages, including the principle of “rolling with resistance) are: reflective listening – For example: Doctor says, “You sound like you are afraid of what life will be like without drugs,”; exploring the pros and cons of continued substance use, affirmations – For example: Doctor says, “I am really proud of you. You are making progress and I know how hard that is, but you are doing it!”; reframing – For example: Patient says, “I have messed up my entire life.” Doctor says, “You have an illness and, under the influence, you made some mistakes. But now you are clean and, while that won’t erase the past, you can now make your life a wonderful one. You are creating your own reality by the positive choices you are now making”, and emphasizing personal control – For example, Patients says,“Doc, I realize my drug use caused a lot of problems and hurt the people I love the most, but I know if I continue to go to meetings and do all the things I am supposed to, I will stay sober and that makes me the one in control, instead of the pills, which used to control me and my actions. Now I may be able to heal and make amends to the people I have harmed—one day at a time.” It should be noted that your patient, obviously, does not live in a “vacuum.” Perhaps their significant other is abusing substances or enabling the patient. Many spouses who have been asking their partner to quit drinking or drugging for years may actually “sabotage” your patient’s sobriety. For example, the wife whose husband has abused alcohol may begin to feel a loss of control when her husband actually seeks treatment and starts attending 12-Step meetings. Her husband may come home stating how wonderful he feels now that he is no longer in active addiction; however, his wife may feel an www . DCMS online . org
incredible amount of resentment from all the years she suffered through her husband’s addiction and also feel jealous about his new-found friendships at meetings. It is not an uncommon theme for the significant other of the recovering addict to retort in a moment of anger, “I liked you better when you were drinking!” Therefore, it is very important for the physician to have a family conference with the patient present and to educate his loved ones about the disease of addiction and the physician and patient’s plan for his recovery. The physician should refer family members to support groups such as Al-Anon and Alateen (www.al-anon.alateen. org; www.jaxafg.org , 904-350-0600) to assist them in understanding what “their” addict is going through in recovery, as well as to help the family develop their own coping mechanisms (i.e., become less codependent, stop enabling behaviors, release resentments and old wounds from when their partner or parent was actively addicted). When your addicted patient stops using substances and is actively involved in a plan of recovery, your once “most difficult” patient can become, ironically, one of your most liked and “best” patients.9
Conclusion Physicians have one of the most honorable, but also most difficult, jobs in the world. They have to see many patients in a short-period of time, thus, many doctors feel a lack of connection. Relating to their patients was one of the reasons they went into medicine. Without a relationship with their patients, “burn-out” can occur. This author believes that physicians must first take care of themselves, so that they may then provide better care to their patients and to their own loved ones. The following 6- step mnemonic, which spells CALMER as an acrostic, may be helpful when dealing with difficult patients, such as “drug seekers.”14
C atalyst for Change: Physicians should always keep in mind
that they are not responsible for their patient’s choices; they are only catalysts to help the patient make the right choices for their overall well-being.
Alter Thoughts to Change Feelings: Cognitive behavioral
theory posits, “We Feel What We Think” and the only way individuals can control their reactions (feelings) is to alter their thoughts about the situation.15 Probably the most important aspect of this step is: Do not personalize your patient’s behavior! Perhaps the patient reminds you of a difficult person in your life (past or present). Take time to introspect when you have strong feelings about a patient. Think about other times in your life when you felt these same strong emotions and attempt to filter out what is your “stuff” (you might be reacting not to the patient; the patient’s troublesome behaviors may actually be causing you distress because you may be reminded of someone in your life who also exhibited these same behaviors which hurt you in some way), and what is actually the patient’s “stuff” (behaviors which all physicians would agree are inappropriate).. Then work to alter your thoughts. For example, a thought such as, “This patient is trying to get me to Northeast Florida Medicine Vol. 63, No. 1 2012 35
prescribe him narcotics” leads to feelings of anger. Replacing that thought with, “This poor guy is terrified and that is why he is so demanding. I’m not prescribing the medication he wants but, no matter how he reacts, I will try to stay calm and empathic—he is a sick person.” You will likely feel less angry and more compassionate. Altering one’s thoughts, although it may sound simplistic, is not an easy task, especially while you are in the midst of a strong emotional state. Sometimes it helps, after the distressful emotions have passed, to ask yourself, “What can I tell myself about this situation that would make me feel less angry, disgusted, sad, etc”?
Prochaska JO, DiClemente CC. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, IL: Dow Jones-Irwin; 1984.
Botelho RJ, Novak S. Dealing with substance misuse, abuse, and dependency. Primary Care. 1993;20(1):50-71.
Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems:a review. Addiction. 1993;88(3):315-335.
Haynes P, Ayliffe G. Locus of control of behavior:is high externality associated with substance misuse? Br J Addict . 1991;86(9):1111-1117.
Rollnick S, Heather N, Gold R, Hall W. Development of a short “readiness to change” questionnaire for use in brief, opportunistic interventions among excessive drinkers.Br J Addict. 1992;87(5):743-754.
Secades-Villa R, Fernande-Hermida JR, Arnaez-Montaraz C. Motivational interviewing and treatment retention among drug user patients: a pilot study. Subst Use Misuse. 2004; 39(9):1369-1378.
Stotts AL, Schmitz JM, Rhoades HM, Grabowski J. Motivational interviewing with cocaine-dependent patients: a pilot study. J Consult Clin Psychol. 2001;69(5):858-862.
Parsons JT, Rosof E, Punzalan JC, DiMaria L. Integration of motivational interviewing and cognitive behavioral therapy to improve HIV medication adherence and reduce substance use among HIV-positive men and women: results of a pilot project. AIDS Patient Care STDS. 2005;19:31-39.
Pomm HA, Pomm RM. Management of the addicted patient in primary care. New York: Springer Publishing; 2007.
Miller WR. Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series (35) 1999. Rockville, MD: U.S. Department of Health and Human Services.
L isten and Then Make a Diagnosis: Medical errors may
result when physician’s negative feelings may cause them to inaccurately hear what their patient is saying. In addition, they may spend much less time with a difficult patient, also possibly leading to missed information. By practicing C and A, the physician is better equipped to truly hear what may be underlying your patient’s actual words (themes of fear, abandonment, etc) and, consequently, make an accurate diagnosis. A quote this author uses often is “Underneath anger is always fear.” Addiction is a fear-based illness. It is likely that the angrier your patient is, the more terrified he/she is.
M ake an Agreement with Your Patient: Whether your agree-
ment is focused on what you have discussed with your patient to move him/her to the next stage of change or an agreement for the patient to go to detoxification, if the patient knows you will be there through this difficult time, it increases their trust and their motivation to change. This step helps both the physician and the patient increase their awareness that they are making a conscious choice to continue their relationship, which, in turn, increases perceived control for both parties.
E ducation and Follow-Up: Depending on where your patient
is in the Stages of Change model, you may need to set aside your own agenda and practice some of the strategies listed in the previous section. This does not mean you shouldn’t set firm boundaries; in fact, difficult patients seem to do better with more structure. You may begin the visit with, “How are you? We only have a short amount of time, so I want to find out where you are in terms of what we discussed last visit.” You may have to see these patients on a more frequent basis; however, by providing the patient education appropriate to his/her Stage of Change,while also setting clear boundaries, and re-directing the patient when they get off track, will also help you and your patient feel more in control.
R each Out and Discuss Your Feelings: Someone once said, “No man is an island.” Physicians are notorious for holding worries, concerns and fears inside—which may be why physicians have a high rate of suicide, depression, divorce and substance abuse themselves! Most doctors are exposed to not only difficult, exhausting patients; they also have to deal with death and other traumatic events in everyday practice (some specialties more than others). It is critically important for the physician to have a trusted colleague or friend with whom they can share their fears and concerns. Again, physicians who take care of themselves are happier and provide their patients—even the most difficult ones—with the best quality of care.
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11. O’Connell D. Behavior Change. In Feldman MD, Christenson JF,eds. Behavioral Medicine in Primary Care. Second Edition. Columbus OH: McGraw-Hill; 2003. 12. Zimmerman GL, Olsen CG, Bosworth MF. A ‘stages of change approach’ to helping patients change behavior. Am Fam Physician. 2000;61:1409-1416. 13. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. 2nd ed. New York: Guilford Press, 2002. 14. Pomm HA, Shahady, E, Pomm RM. The CALMER Approach: Teaching Learners Six Steps to Serenity When Dealing with Difficult Patients. Fam Med 2004;36(7):467-469. 15. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press,1979.
In addition to these references, for more information on Motivational Interviewing seminars and workshops for CME, please visit: http://www.motivationalinterview.org/ www . DCMS online . org
Trends in Public Health
Substance Abuse and Our Teens James B. Tidwell, MPH: Thomas Bryant III, MSW; Niketa Walawalkar, MD, MPH; and Robert Harmon, MD, MPH Teenage substance abuse is a dangerous public health problem. According to the 2011Youth Risk Behavior Survey (YRBS), those who use alcohol before age 15 are five times more likely to become alcohol dependent than those who begin drinking at or after age 21. Heavy alcohol drinking among youth is associated with use of cigarettes, marijuana, cocaine, other illegal drugs, and risky sexual behaviors. Smoking increases the risk of heart disease, lung disease, respiratory illness, stroke, and many forms of cancer. In addition to negative health effects, smoking and using drugs are also associated with violence, delinquency, and suicide.
higher than for females. In some cases, male rates were more than double the female rates, including recent marijuana use on school property, current use of smokeless tobacco, and ever using ecstasy. However, female rates of current inhalant use and lifetime alcohol use were higher. Current alcohol use on school property also increased overall from 2009 to 2011 driven by female rates increasing from 5% to 6.3% despite slight decreases from 6.4% to 6.2% for males. Targeting the root causes of higher male rates and investigating worrisome trends among females are vital considerations for substance abuse program planning.
YRBS is a national survey of risk behaviors conducted in public schools. The Centers for Disease Control (CDC) has conducted the survey every two years since 2001. Duval County Public Schools (DCPS) obtained federal funding beginning in 2009 to administer the survey to a random sample of classes from every public middle and high school in the county. Results are weighted to ensure they represent the entire DCPS student population.
There are also significant geographic disparities in teenage substance abuse. Health Zone 1 (HZ1/the Urban Core) had the lowest rates for current use of cigarettes, smokeless tobacco, and alcohol, as well as lifetime alcohol use and binge drinking. HZ1 also was relatively low for lifetime methamphetamine inhalant use and average for current marijuana and cocaine use. HZ6 (the Beaches) was highest among all health zones for all of those categories except for current smokeless tobacco use where only HZ5 (the Outer Rim) was higher. Additional research into the sources of these disparities and resource allocation proportionate to the inequalities is essential.
Substance abuse is widespread in Duval County although some measures are improving. Alcohol is the most abused substance among Duval teenagers according to YRBS. In 2011 36.5% of middle schoolers reported ever having a drink compared to 43.8% in 2009. High school alcohol use remained unchanged over the same period. Current alcohol use (35.6%) and binge drinking (17.6%) among high schoolers were both slightly lower in our county than in the state of Florida (37% and 19.1%) and were statistically significantly lower than national figures (41.8% and 24.2%). Tobacco is the second most abused substance among teenagers. However, the percentage of middle school students who smoked cigarettes in the past 30 days decreased from 8.1% to 5.1% between 2009 and 2011 and high school rates decreased from 15.4% to 12.4%. Encouragingly, current high school smoking prevalence in 2011 is 13% lower than the statewide rate and almost half of current smokers reported trying to quit in the last year. Drug use among high school students did not change for cocaine and marijuana but decreased for inhalants, methamphetamines, ecstasy, and steroids. Startlingly, one-third of all high school students reported that they were offered, sold, or given an illegal drug by someone on school property in the previous 12 months. Substance abuse reduction efforts in schools must include students, teachers, parents, law enforcement and the community to address this problem. Teenage substance abuse rates for males were generally www . DCMS online . org
Many school-based programs in Duval County, like Zeroing In on Prevention (ZIP), Safe and Drug-Free Schools, Drug Free Youth Incentives (D-FY-INCE), and the Night-Time Substance Use Prevention Counseling Education Program, seek to reduce teenage substance abuse. They help reduce risk factors, increase protective factors, provide voluntary drug testing and abstinence rewards, and empower parents to protect their own teenagers. In addition to preventative programs, effective treatment is necessary to help those who are already suffering the effects of substance abuse. While programs funded through the Department of Children and Families treated more than 2,000 individuals under the age of 18 years in FY2010, only 35% of those in Duval County completed their treatment compared to 63% statewide. Programs to help those who seek treatment must strive for high completion rates to limit repeat substance abuse. Despite successful efforts in Duval County, substance abuse remains a leading public health concern. The scientific literature shows that prevention and early intervention programs, strong follow-up after treatment, more appropriate accessibility restrictions, and regulation of substance composition and marketing are known to reduce the harms of substance abuse. It is important to continue to implement programs and policies to educate teenagers about substance abuse and provide stronger prevention, treatment, and recovery programs. Northeast Florida Medicine Vol. 63, No. 1 2012 37
38 Vol. 63, No. 1 2012 Northeast Florida Medicine
www . DCMS online . org
AMA Leadership Visit in April Jeremy A. Lazarus MD, the current President-Elect of the American Medical Association (AMA), will visit Jacksonville April 15-17, 2012. (The DCMS Leadership Dinner is April 16. Watch for details.) Dr. Lazarus will become the 167th AMA President in June, 2012. He is only the second psychiatrist in the AMA’s history to be elected to the position and the first since 1939. While in the area, Dr. Lazarus will speak at a DCMS dinner meeting, be keynoter at the Jacksonville Rotary Club, visit local academic medical institutions, The Florida Times-Union Editorial Board, Naval Hospital Jacksonville, and other area groups. The Jeremy A. Lazarus, MD DCMS has been hosting AMA AMA President-Elect leadership for more than 20 years as a way to broaden the community’s knowledge of organized medicine and to help motivate grassroots advocacy on issues of national importance.
Colorado Denver School of Medicine and a voluntary professor of psychiatry at the University of Miami Leonard M. Miller School of Medicine, Dr. Lazarus is a distinguished fellow of the American Psychiatric Association and is widely published on issues of ethics, economics and managed care. His most recent book is entitled Entering Private Practice: A Handbook for Psychiatrists. Northeast Florida will be well represented in the AMA delegation and at the AMA Annual Meeting June 16-20 in Chicago, IL. The following are physicians serve as delegates or alternate delegates either from the Florida Medical Association or the indicated specialty societies and group.
• Yank D. Coble, Jr., MD, MACP, MACE/Past AMA President (2002-2003) • W. Alan Harmon, MD - Florida Delegate/FMA • Nathan P. Newman, MD - Florida Delegate/FMA • Ashley Booth Norse, MD - Florida Alt. Delegate/FMA • John M. Montgomery, MD, MPH - Florida Alt. Delegate/ FMA • Thomas G. Peters, MD - Florida Alt. Delegate/FMA • Daniel Kantor, MD, BSE - Florida Alt. Delegate/FMA ACS SaveThe Date horiz:Layout 1 1/25/12 9:31 AM Page 1• Eli N. Lerner, MD - Delegate/Society of American Gastrointestinal Endoscopic Surgeons A clinical professor of psychiatry at the University of
The American Cancer Society’s
17 Annual Cowford Ball
Saturday, April 21, 2012
Jacksonville Fairgrounds, 6:00 p.m. For more information and to order your tickets, please contact: Therese Yanochik at the American Cancer Society at 904-391-3613 or email@example.com. Information also available at cowfordball.org. Sponsorship opportunities available. Presented by
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Northeast Florida Medicine Vol. 63, No. 1 2012 39
A Word of Thanks to Our Physician Volunteers Dr. Malik Abraham Dr. Scot Ackerman Dr. Kenneth Adams Dr. Vaqar Ali Dr. Leonardo Alonso Dr. Youssef Al-Saghir Dr. Syed Asad Dr. Majdi Ashchi Dr. Duncan Baker III Dr. Leslie Beadling Dr. Richard Beck Dr. Janet Betchkal Dr. William Brandon Dr. Jeffrey Brink Dr. James Burt Dr. Vincent Caracciolo Dr. John Casler Dr. Gerardo Colon Dr. Steven Crenshaw Dr. Gary Decker Dr. Salim Ghazi Dr. Nelson Goldman Dr. Floyd Gonder Dr. Sanjiva Goyal Dr. David Grech Dr. A.L. Green Dr. Jack Groover Dr. John Harris Dr. Kevin Hayes Dr. Howard Hogshead Dr. Charles Homra Dr. Amy Jarvis Dr. Margaret Johnson Dr. Yazan Khatib Dr. Aalok Kuthiala
Dr. Sumant Lamba Dr. Jeffrey Levenson Dr. Richard Lewis Dr. Juzar Lokhandwala Dr. Michael Lutz Dr. John Mazur Dr. Charles McIntosh Dr. Dennis McDonagh Dr. George Miguel Dr. Mohammed Mona Dr. Ted Montgomery Dr. Dawn Mussallem Dr. Photis Nichols Dr. Sean Orr Dr. Dinesh Pubbi Dr. Prithviraj Rai Dr. Douglas Robins Dr. Renato Romero Dr. Juan Rosario Dr. Howard Rose Dr. Eric Rosemund Dr. Miguel Roura Dr. Neil Sager Dr. Craig Shapiro Dr. Timothy Schneider Dr. Chris Scuderi Dr. Mona Shah Dr. D.M. Shetty Dr. David Shin Dr. James Smart Jr. Dr. Edward Smith Dr. Timothy Sternberg Dr. David Sutton Dr. Robert Van Cleve Dr. David Weisman Dr. Carl Davis Whelchel Dr. John Whittaker Dr. Timothy Woodward Dr. Omer Zuberi
40 Vol. 63, No. 1 2012 Northeast Florida Medicine
Volunteers in Medicine Jacksonville Volunteers in MedicineJacksonville, a volunteer-run primary care clinic, wishes to thank the physicians who give of their time to provide access to care for the working uninsured. Providing free, quality healthcare for our working uninsured patients 41 East Duval St., Jacksonville, FL 32202 Phone: (904) 399-2766 Fax: (904) 549-8300 Website: www.vim-jax.org
VIM-JAX Requests Physician Volunteers Physicians can volunteer as little as 4 hours a month. Primary care/ internal medicine physicians are an ongoing need. For more information, contact Catie Wallace at firstname.lastname@example.org or (904)-3992766 x103.
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DCMS Membership Applications These physicians’ applications for membership in the Duval County Medical Society are now being processed. Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Ashley Booth Norse, MD, DCMS President (904-244-4106) or Barbara Braddock, Membership Director (904-355-6561 x107).
Taufiq U. Ahmed, MD Anesthesiology UF Anesthesiology Medical Degree: West Virginia University School of Medicine Residency: Emory University Hospital Fellowship: Virginia University/Fontaine Medical Office Nominated by: UFJP Jon C. Allmon, MD Vascular Surgery UF Surgery Medical Degree: Georgetown University School of Medicine Residency: Tulane University School of Medicine Fellowship: Washington University School of Medicine Nominated by: UFJP Nitin S. Butala, MD Neurology/Clinical Neurophysiology Baptist Medical Center/Baptist Neurology-Lakewood Medical Degree: Grant Medical College Residency/Fellowship: Medical College of Wisconsin Nominated by: Mobeen Rathore, MD; Carlos Gama, MD; Rebecca Cooper, MD Amanda L. Cooper, MD Internal/Geriatric Medicine Baptist Primary Care-Internal Medical Group, Inc. Medical Degree: University of Illinois at Chicago Medical School Residency: University of Pennsylvania Medical School Nominated by: Richard Glock, MD; Richard Grochmal, MD; Joseph Stepp, MD Jesus A. Diaz, MD Pulmonary Medicine UF Pulmonology Medical Degree: Autonomous University of Cindad Juarez School of Medicine Residency: Texas Tech University
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Health Sciences Center Fellowship: State University of New York & Baylor College of Medicine Nominated by: UFJP
UF Maxillofacial Surgery Medical Degree: University of Adelaide Internship/Residency: University of Adelaide Hospital Residency: Royal Darwin Hospital Nominated by: UFJP
Carlos M.C. Fernandes, MD Otolaryngology UF Otolaryngology Medical Degree: University of Witwatersrand Johannesburg Internship: Johannesburg and Baragwanath Hospitals Residency: University of Witwatersrand Johannesburg Nominated by: UFJP
Jade L. Pizarro, MD Obstetrics & Gynecology Care Center for Women @ Shands Medical Degree: University of South Florida College of Medicine Residency: University of Cincinnati Hospital Nominated by: UFJP
Emily Fontane, MD Emergency Medicine UF Emergency Medicine Medical Degree: University of Pennsylvania Medical Center Residency: University of Maryland Medical System Nominated by: UFJP Robert J. Kim, MD Cardiology The Cardiovascular Center/UF Medical Degree: Tufts University Internship: St. Elizabeth’s Medical Center Residency: University of Massachusetts Medical School Fellowship: Dartmouth-Hitchcock Medical Center Nominated by: UFJP Sylkia M. Martinez-Cruz, MD Pediatrics South Jacksonville Health Center Medical Degree: University of Puerto Rico Residency: San Juan Bautista Medical Center Nominated by: UFJP Chirag J. Patel, MD Ophthalmology UF Ophthalmology Medical Degree: University of Florida College of Medicine Internship: Richmond University Medical Center Residency: The Mount Sinai Medical Center Nominated by: UFJP Phillip Pirgousis, MD, DMD Maxillofacial Surgery
Joseph R. Shiber, MD Emergency Medicine UF Emergency Medicine Medical Degree: University of Maryland Residency: University of Maryland Fellowship: R. Adams Cowley Shock Trauma Center, University of Maryland Nominated by: UFJP Patricia A. Solo-Josephson, MD Pediatrics UF/Beaches Family Health Center Medical Degree: University of Miami School of Medicine Residency: Jackson Memorial Hospital Nominated by: UFJP Shelly H. Thompson, MD Pediatrics Duval County Health Department Medical Degree: University of Florida College of Medicine Residency: University Medical Center Nominated by: UFJP
Did you know about this?
Referral? Phone Number? Address or Directions? Use the DCMSonline Physician Directory on your Smartphone!
You can easily search for a DCMS member’s practice information and get a map and directions to their office. Check it out
www.db.dcmsonline.org/directory or use your SmartPhone QR reader!
Go online and take a look!
Northeast Florida Medicine Vol. 63, No. 1 2012 41
Dr. Booth Norse Inaugurated 125th DCMS President and Awards Presented During 159th DCMS Annual Meeting Ashley Booth Norse, MD, was inaugurated as the 125th president of the Duval County Medical Society (DCMS) at its 159th Annual Meeting, Thursday, December 1, 2011 at the Hyatt Regency Jacksonville Riverfront. Her husband, Ronald Norse, administered the Oath of Office. (see left) She is only the third woman president of the Society. (Predecessors were Dr. Kay Gilmour in 1992 and Dr. Kay Mitchell in 2003). Dr. Gilmour and Dr. Mitchell were present at the meeting and received special recognition. (see photo p. 43) Dr. Booth Norse specializes in Emergency Medicine and is Assistant Professor in the Department of Emergency Medicine at the University of Florida, Shands Jacksonville. She is ABEM boarded (American Board of Emergency Medicine) and at Shands she is an academic physician who trains resident physicians. Besides her teaching efforts, Dr. Booth Norse is not only active in DCMS but also in the Florida Medical Association, American Medical Association, the American College of Emergency Physicians (ACEP) and the Florida College of Emergency Physicians. She serves on committees and boards, is a delegate to state and national meetings, is a Fellow of the ACEP, (FACEP), and is also an officer in some groups. Dr. Booth Norse was DCMS President-Elect before being inaugurated as the DCMS President. The major goals for her presidency are to first “reassess the needs of the DCMS members and ensure that the Society is providing the services and resources the membership needs.” Next, it is important to “continue to try to improve DCMS membership numbers” which have declined in recent years. Finally, she hopes “to increase the presence and role of the DCMS in the state regulatory and legislative arena.” During the meeting, DCMS and FMA Past Presidents were recognized as well as special guests. Annual elections took place, bylaws amendments were passed, and the slate of officers, directors, FMA delegates and alternate delegates was approved. Eli N. Lerner, MD, was elected as DCMS President-Elect. (see right top, Dr. & Mrs. Lerner and right bottom, Dr. & Mrs. Foster.) Other 2012 officers are: Vice Presidents Neel G. Karnani, MD and Mobeen Rathore, MD; Daniel Kantor, MD, secretary; Nathan P. Newman, MD, treasurer; and 42 Vol. 63, No. 1 2012 Northeast Florida Medicine
Malcolm T. Foster, Jr., MD, immediate past president. The 2011 DCMS Board of Directors was recognized and thanked for their efforts. George Trotter, MD, gave the traditional Roll Call. Dressed in 1880s attire, he called the name of “Francis P. Wellford, MD” as a way to honor this important DCMS Past President who died in 1887 after treating those afflicted with Yellow Fever. A moment of silence tribute was observed for members who died in 2011. DCMS Life Members (members for 35 years) recognized were: Carmelita E. Garcia, MD; M.F. Mass, MD; Thomas A. Michelsen, DO; Edward A. Mizrahi, MD; H. Martin Northup, MD; Neil Sager, DO; John R. Whittaker, MD; and Dale F. Zimmerman, MD. Speakers on the program were FMA President Dr. Miguel Machado who declared “Medicine is alive and kicking,” while encouraging DCMS members to support key health care bills in the 2012 legislative session. Dr. Machado presented an FMA Certificate of Appreciation to Dr. Hong T. Tek. (see above Dr. Tek, Dr. Machado & Dr. Foster) DCMS Foundation President Dr. Benjamin Moore reminded the audience of the decision to sell the DCMS Bishopgate Lane property to help improve the Society and Foundation’s finances and free them to undertake some key projects. Mrs. Dena Pulley, DCMS Alliance President, encouraged membership in the Alliance and presented a gift to Ronald Norse, husband of Dr. Booth Norse. (See right) Awards were also presented. Daniel Kantor, MD, received the 2011 Philip H. Gilbert Young Physician Leadership Award, created to honor the memory and service of Philip H. Gilbert, Executive Vice President of the DCMS from 1984 until his death in 2004. (see p. 8) Thomas G. Peters, MD, received the 2011 Clyde M. Collins Humanitarian Award (see left) in recognition of his dedication and commitment to the transplant community in Continued to p. 44 www . DCMS online . org
159th DCMS Annual Meeting in Photos
(Top to bottom, left to right) Dr. Booth Norse's husband, Ronald, presents her with flowers to celebrate her inauguration as DCMS President; Dr. Allen Seals, Dr. Kay Gilmour and Dr. Guy Selander enjoy the evening and each other's company; Alex Mitchell and Dr. Kay Mitchell; Three DCMS Female Presidents: Dr. Mitchell, Dr. Booth Norse and Dr. Gilmour; Poster presentation by Dr. Sadaf Saghier (pictured) and Dr. Anthony Perszyk; Dr. John Montgomery, Dr. Miguel Machado, Dr. Eugene Rawson Griffin, III, and Angie Nykamp in Exhibit Hall; Dr. Foster and Life Member Dr. Neil Sager; Russell Jackson FMA VP, Florida Senator John Thrasher and Jay Millson; Dr. Booth Norse delivers her inauguration speech.
Fond Farewell to EVP Jay Millson
Jay Millson left his position as DCMS Executive Vice President on February 1, 2012 to become EVP for the Florida Academy of Family Physicians. In her inaguration speech, Dr. Booth Norse said, "Jay has made the EVP job look easy... he is so qualified and capable. I wish him great success in his next endeavor." Jay said in his resignation letter to the DCMS Board of Directors, "Since coming to the DCMS in 2004, I have thoroughly enjoyed continuing the remarkable traditions of this storied medical society...I have considered it an honor and a pleasure serving the physicians of NE Florida." The DCMS Distinguished Service Award Jay Millson received stated, "Your keen insight and leadership abilities have been evident in the positive changes and successful accomplishments the Medical Society has experienced under your strong, supportive leadership." Jay Millson receiving a DCMS Distinguished Service Award ( above Jay Millson, Dr. Booth Norse and Dr. Malcolm Foster, Jr.) www . DCMS online . org
An introduction of the new DCMS EVP Bryan Campbell is on page 9. Northeast Florida Medicine Vol. 63, No. 1 2012 43
Continued from p. 42
Duval County, throughout Florida, in the Southeast and across the nation. Dr. Peters is a surgeon specializing in transplant surgery. This award was created in 1997 in memory of Dr. Clyde Collins to recognize volunteer efforts by physicians. Sudhir L. Prabhu, MD, received the 2011 DCMS Community Service Award. (see left Dr. Prabhu, Dr. Joshi & Dr. Foster) Dr. Sunil Joshi assisted in presenting this award to his colleague, Dr. Prabhu, who specializes in pediatric allergies, is committed to the community, and volunteers countless hours in the delivery and education of asthma care to the less fortunate in Jacksonville and the greater Northeast Florida area. The DCMS Community Service Award was established in 1998 to recognize the outstanding volunteer efforts of the DCMS Physicians that have been performed outside of DCMS sponsored activities. Guest Editors for 2011 issues of Northeast Florida Medicine were presented with commemorative plaques by Editor-in-Chief Dr. Raed Assar and Dr. Foster. (see above) They were: Dr. Ziad Awad, Dr. Janet Betchkal, (not present) Dr. Steven Cuffe and Dr. Daniel Kantor. Dr. Foster was presented a President’s Plaque and Past President’s Pin. (see right with Dr. Booth Norse) Special features at the Annual Meeting were Poster Presentations by DCMS members and resident physicians. (see p. 43) Another feature was an informational booth about the DCMS Historical Book project. The book, entitled “Florida’s Pioneer Medical Society: A History of Duval County Medical Society and Medicine in Northeast Florida” will be published spring of 2012. (see order form, p. 10) There was a full Exhibit Hall area featuring vendors displaying their products and services. (see p. 43)The Platinum Sponsor of the Annual Meeting was The Doctors Company (formerly FPIC) and Gold Sponsors were Baptist Health, Blue Cross Blue Shield of Florida, Signet Diagnostic, SunTrust Bank, and the University of Florida College of Medicine – Jacksonville. There were Silver and Exhibitor Sponsors as well. They were: (Silver) Availity, LLC; Brooks Rehabilitation; 44 Vol. 63, No. 1 2012 Northeast Florida Medicine
Community Hospice of NE Florida; Life Planning Partners, Inc.; Nova SE University - PA Program; Professional Medical Insurance Svs.; Southland Recycling Services; The Diamond Group; Vandroff Insurance Agency and (Exhibitor) Akerman Senterfitt; AstraZeneca LP; Beson 4 Media Group; DCMS Historical Book Project; Heartland Rehabilitation; Heritage Publishing, Inc.; Jacksonville Sports Medicine Program; Mayo Clinic-Referring Physician Office; Medi Track, LLC; NE FL Medical Legal Partnership; Purdue Pharma, LP; Ray Howard & Associates; Warner Chilcott Pharmaceuticals and We Care Jacksonville.
2011 Donations to the DCMS Foundation Chalermchai Punya, MD Christopher Goll, MD Eugene Rawson Griffin III, MD Gavin Duffy, MD George Mayer, MD Guy T. Selander, MD J. Eugene Glenn, MD Janet A. Betchkal, MD Joseph R. Hartigan, MD Kay Mitchell, MD Kevin Murphy, MD LBA Wealth Management Lynn H. Norman, MD Marianne B. McEuen, MD Mihaela Ionescu, MD P. Andrew Coley, MD Paul Shirley, MD R. Stephen Lucie, MD Rahul Deshmukh, MD Richard G. Skinner, MD Robert E. Duncan, MD Russell D. Metz, MD Steven Crenshaw, MD Timothy Sternberg, MD Walter R. Gilbert, Jr., MD Yank D. Coble, Jr., MD
THANK YOU! www . DCMS online . org
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Northeast Florida Medicine Vol. 63, No. 1 2012 45
Order 2012 DCMS Directories today! The 2012 Duval County Medical Society Membership Directories are now available! With this directory, you’ll have contact information for members of the following County Medical Societies: • • • • •
Duval County Medical Society Clay County Medical Society Nassau County Medical Society Putnam County Medical Society St. John's County Medical Society
The Directory also includes Hospital and Clinic contact information, Frequently Asked legal questions, Legislative contact information, and lots more! Use the form below to order copies of your 2012 DCMS Directory today!
2012 DCMS Membership Directory Order Form Physician’s Name: ____________________________ Office Contact: _________________________ Address: _________________________________________________________________________ City: _______________________________ State: _____ Zip: ______ Phone #: _______________
Member of: ___ Duval County Medical Society
CMS Member Rate - $15.00 per Directory
___ Clay County Medical Society
# of books ____ @ $15.00 each
___ Nassau County Medical Society ___ Putnam County Medical Society
+ 7% sales tax
+ Shipping & handling
___ St. Johns County Medical Society ____ Check (payable to DCMS) enclosed ____ Charge to the following account (circle one):
Shipping and Handling Charges
Account # ________________________________ Exp date ____
1 Directory 2-4 Directories 5-10 Directories 11-20 Directories 20+ Directories (couriered)
You can also pick up your Directories at the DCMS office and avoid shipping charges.
$ 4.00 $ 6.00 $ 8.00 $12.00 $18.00
Mail or FAX to: Duval County Medical Society * 555 Bishopgate Lane * Jacksonville, FL 32204 * FAX (904) 353-5848 For questions, please call 355-6561
46 Vol. 63, No. 1 2012 Northeast Florida Medicine
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Our Spring 2012 issue on Addiction Medicine was guest edited by DCMS member Dr. Raymond M. Pomm. It offers CME credit on Domestic Violence....