Opioids: Addressing the Crisis of a National Epidemic

FP JULY-SEPTEMBER 2018

MISSOURI FAMILY PHYSICIAN

OPIOIDS: ADDRESSING THE CRISIS OF A NATIONAL EPIDEMIC

FAMILY MEDICINE FACULTY POSITION Saint Louis University, a Catholic, Jesuit institution dedicated to student learning, research, health care, and service is seeking applicants for full-time or part-time faculty positions at the rank of Assistant Professor in the Department of Family and Community Medicine.

Board-certified family physicians with strong clinical skills and a commitment to training future family physicians are sought for clinical and academic faculty positions in a vibrant and collaborative department.

Practice options include: • Clinical ambulatory practice with faculty colleagues in an innovative Patient Centered Medical Home on the campus at Saint Louis University.

• Clinical ambulatory practice with an urban underserved population.

Combined with ambulatory practice, we provide opportunities for teaching medical students, teaching and mentoring residents, and participating in inpatient medicine.

Support and mentorship is provided for scholarship and research.

Application must be made online at http://jobs.slu.edu and include cover letter and curriculum vitae.

Applicants may contact the department directly by calling 314-977-8480, by sending CV and cover letter to Christine Jacobs, M.D., Professor and Interim Chair, Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104, or via e-mail to christine.jacobs@health.slu.edu

Saint Louis University is an equal opportunity/affirmative action employer. All qualified candidates will receive consideration for the position applied for without regard to race, color, religion, sex, age, national origin, disability, marital status, sexual orientation, military/veteran status, gender identity, or other non-merit factors.

We welcome and encourage applications from minorities and women.

FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

BOARD CHAIR Mark Schabbing, MD (Perryville) PRESIDENT Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT-ELECT Jamie Ulbrich, MD, FAAFP (Marshall) VICE PRESIDENT John Paulson, MD, PhD, FAAFP (Joplin) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

CONTENTS 12 OPIOIDS:

ADDRESSING THE CRISIS OF A NATIONAL EPIDEMIC

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR John Burroughs, MD (Kansas City)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Robert Schneider, DO (Kirksville)

ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Kara Mayes, MD (St. Louis)

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Vacant

ALTERNATE Vacant DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo)

ALTERNATE Charlie Rasmussen, DO, FAAFP (Branson) DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Deanne Siemer, MD (Jackson)

ALTERNATE Vicki Roberts, MD, FAAFP (Cape Girardeau) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

RESIDENT DIRECTORS Alicia Brooks, MD, SLU Ann Lottes, MD, SLU (Alternate)

STUDENT DIRECTORS John Heafner, MD, MSPH, SLU MiMi Liu, SLU (Alternate)

4 Annual Reports A Year in Review

12 Issue Focus: Opioids

Addressing the Crisis of a National Epidemic

38 Show Me Family Medicine Conference A Recap of SMFM

41 2018 Family Physician of the Year Meet David Campbell, MD, FAAFP

44 New MAFP President Dr. Cole Takes Presidential Oath

48 Members in the News Recognizing our Colleagues

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MARK YOUR CALENDAR

EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE COMMUNICATIONS & EDUCATION MANAGER Sarah Mengwasser MEMBERSHIP & PROGRAMS COORDINATOR Becki Hughes

AAFP National Conference of Family Medicine Residents & Students (NCFMRS) August 2-4, 2018 Kansas City Convention Center Kansas City, MO

The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

Family Medicine Transition Conference August 17-18, 2018 Double Tree Hotel Jefferson City, MO

MAFP STAFF

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 mo-afp.org • office@mo-afp.org

Annual Fall Conference November 9-10, 2018 Big Cedar Lodge Ridgedale, MO

MO-AFP.ORG 3

ANNUAL REPORTS

Kathleen Eubanks-Meng, DO, Outgoing Board Chair

A

s I wrap up my last year of service on the MAFP board, I look back at how far we have come as an organization and as a profession. As I took the helm as president of MAFP in 2016, I noted that “I am not Wonder Woman” during my installation speech. We all strive to be a super hero, but sometimes we are just the ‘Underdog” – “Have no fear, the underdog is here.” We all play both of these roles interchangeably every day – and we keep flying from patient room to patient room, listening, caring, and treating our patients. There is never enough time, but we make the time…

We are family physicians.

"It is so important for each of us to commit to “fight for family medicine” each and every day, but especially during the five months our elected leaders are in Jefferson City."

We welcomed new governmental consultants this year, Randy Scherr and Brian Bernskoetter, who were actively advocating for family medicine and sharing our message at the capitol. It is so important for each of us to commit to “fight for family medicine” each and every day, but especially during the five months our elected leaders are in Jefferson City. As I transition away from the board, I challenge each of you to contact your legislator on issues that impact your profession and practice.

The MAFP priorities are included in the weekly legislative updates, January-May, and a complete

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

list of bills are available on the website. When a legislator receives feedback from a constituent, there is more “super-power” in that one voice than any other person. Regardless of your position compared to MAFPs, your action is needed! We are not the “underdog.”

The MAFP again hosted an Advocacy Day where our white coats were scattered through the halls of the Capitol building. This year’s issues focused on collaborative practice agreements with APRNs, PAs, and APs. Yes, assistant physicians, and we opposed legislation that would have expanded their scope of practice. We were successful and only clean up language was passed. And, the reason we are family physicians, we always advocate for access to quality health care for our patients.

The MAFP submitted a letter to former Governor Eric Greitens when he, and his cabinet leadership, implemented the CDC Guidelines for Prescribing Opioids for Chronic Pain. Since these are guidelines, and are voluntary, we need to express our concerns to him. We collaborated with other health care groups on this issue, and the final outcome is yet to be seen.

Missouri was the host state for the annual Multi-State Forum in Dallas, Texas. Our leadership, along with our Executive Director, Kathy Pabst, represented Missouri among the other 12 states’ delegates. This two-day conference is an opportunity for states to share best practices, challenges, and other important issues that may impact their states and/or chapters. Grant Hoekzema, MD, Mercy Family Medicine Residency, talked about the new assistant physician mid-level provider which some states had never heard of before. Other experts were on hand and provided innovative ideas for practice transformation, how to expand advocacy efforts, and physician wellness.

Although I will no longer serve on the board, I will continue to work with you, promote family medicine, and advocate for our specialty. I am thankful for the opportunity to have served with and beside some of the best and brightest physicians advocating for our profession and our patients.

ANNUAL REPORTS

Mark Schabbing, MD, Board Chair

I

would like to take a minute to thank those who were able to attend our Show Me Family Medicine Conference in Camdenton, Missouri. I believe this was another event that was successfully managed by our staff. We were able to hear from Teri Ackerson, BSN, RN, SCRN, CNRN, give an inspiring talk about her struggle with surviving a stroke. We heard her courageous story and what she has done for stroke and cardiac care on a national and international stage.

Sarah Cole, DO, our new president, talked about her visions for the MAFP this coming year. She plans on traveling the state and reaching out to our members to hear your needs. She wants to hear your expectations of what our chapter can do moving forward. If you were not able to attend the conference this year, I am making a personal invitation for you to join us next year where we will be moving to Tan-Tar-A Resort in Osage Beach.

The dates are June 19-20, 2019.

We do so many things for our members, but one of the unique things is providing advocacy for us and our patients. We have an Advocacy Commission, co-chaired by Keith Ratcliff, MD, and Peter Koopman, MD. They host conference calls with our lobbyists, Randy Scherr, Brian Bernskoetter, and Kathy Pabst, our executive director. In February of each year, we host an Advocacy Day in Jefferson City where we are presented a quick review of pertinent bills being guided through the legislature that affect us and our patients.

Our staff helps by setting up appointments with our representatives and senators where we can express our personal thoughts and positions on what is going on in the Capitol.

Brian Bernskoetter and Randy Scherr, have taken over for Pat Strader who served us very well for more than 15 years. Brian and Randy took over this year and did not miss a beat. In today’s environment, a soft drink can be made to look political on the hill. Unfortunately, it seems like every topic has to become partisan. The MAFP, as well as the AAFP, has done an excellent job with our political actions committees (PACs) not to appear partisan. We have favorable opinions on both sides of the aisle. This past year, we tackled issues on scope of practice with the nurse practitioners, opioid regulations, radiology technician regulations, motorcycle helmet laws, texting and driving, medical marijuana, and many others. Next year we will be dealing with many of the same issues, and believe marijuana will be pushing to the front.

For our board to better serve you, it would be nice to hear how you feel about some of these issues. You will have an opportunity to voice this as Dr. Sarah Cole travels through our state. In addition, we will continue to send out surveys addressing controversial issues.

These surveys are valuable as the aggregate responses are the foundation which the board uses to form a position on an issue, and wishes to support the will of our members. We will be sending out an advocacy survey soon, please take a few minutes to fill it out.

Next, I would like to ask you to make a commitment to our PAC. It is important to find legislators who support our beliefs and our mission of supporting our members and patients. To do so, we in turn need to show that we support them. Donations to a legislator should not be thought to be given to help a specific bill or issue, but more of supporting us and our issues for the long term. The MAFP reaches out to members of the Missouri legislature on both sides of the aisle.

It is not in our interest to be partisan. All of our issues should be looked at as helping health care as a whole, and that should be bipartisan. We are a strong organization with over 2,400 members, but our PAC is deadly anemic. Our PAC typically has a balance of about $3,000.

Here is an idea of what other similar organizations have in their PAC accounts: PAC Total Receipts this Cycle Missouri Nurses Association $3,615 MSMA $209,220 Missouri Insurance Coalition $190,000 *COH between their two PACs Missouri Health Care Leadership PAC $357,970 *managed care PAC Missouri Dermatologist PAC $20,050 MO Society of Anesthesiologist $73,373 COH Blue Cross Blue Shield $100,000 Missouri Hospital Association $88,540 COH PT PAC of Missouri $27,674 COH MAOPS $49,807 Missouri ER Physicians $21,428 * COH – Cash on Hand I would like to think that with a little effort, we could gradually grow the MAFP PAC to nearly $30,000. It is easy to give to the PAC by simply going to our website.

Our staff sent out a burst email earlier this year and we received one response. Please consider donating.

This is an election year and it is very important in helping us be successful in the future. As a reminder, the Fall conference is always a popular event at Big Cedar Lodge. I encourage you to mark your calendar and consider pre-registering early and make your hotel reservation – the lodge always sells out! I wish you all a fun, and safe summer.

MO-AFP.ORG 5

ANNUAL REPORTS

Sarah Cole, DO, FAAFP, President

W

hile continuing as the Education Commission Co-chair, I joined the Executive Commission in summer 2017 as the President-elect. I have learned a great deal about the history of the Missouri Academy of Family Physicians, its operations and networking during the monthly executive conference calls. The winter and spring have been busy with a variety of live meetings.

In December, I attended the Missouri Health Care Workforce Coalition meeting to refine initiatives directed toward increasing the volume of primary care providers in underserved areas of our state, particularly rural counties. I look forward to partnering with the Coalition to advance ideas such as tax credit incentives for rural preceptors or expanding rural training sites.

In January 2018, I joined Drs. Mark Schabbing, Todd Shaffer, and James Stevermer, along with MAFP lobbyists Randy Scherr and Brian Bernskoetter, for a meeting with Dr. Randall Williams, Director of Missouri Department of Health and Human Services. Dr. Williams appeared authentically interested in the group’s insights into the opioid crisis, physician workforce, and physician wellness in Missouri.

Later that same day, I attended the St. Louis Academy of Family Physicians annual meeting to install its new Board of Directors, including Lauren Wilfling, DO, as President and Chris Blanner, MD, as Vice-President and to thank Christine Jacobs, MD for her years of service as she transitioned to Immediate Past President.

With Drs. Schabbing, Ulbrich, and Executive Director, Kathy Pabst, I attended the AAFP MultiState Forum in Dallas, Texas in January. Missouri hosted this year’s forum and I give my thanks to Kathy, Sarah Mengwasser and Becki Hughes for their creativity and hard work in organizing the event. AAFP President, Michael Munger, MD, described AAFP’s proposed alternative payment model for primary care and additional speakers gave information regarding best practices and legislative updates from other state chapters. It was illuminating to learn where our advocacy interests intersect with other states.

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

In February, I was pleased to see how many medical students, residents and family physicians from across our state came together in Jefferson City for Advocacy Day to meet face-to-face with state representatives and senators. It was also a chance for members to meet our new lobbyists, Mr. Scherr and Mr. Bernskoetter.

I was grateful to MAFP for the opportunity to attend the AAFP Annual Chapter Leadership Forum (ACLF) in Kansas City in April. I intentionally participated in sessions related to engagement of state chapter members and discernment of meaningful services that state chapters can offer.

As I work with the Executive Commission and the

"I was inspired by the stories of Missouri’s constituents – in every way possible, they represent the breadth, depth and diversity of our specialty!"

Board to set my goals for the coming year, I hope to incorporate some of these ideas. The National Conference of Constituency Leaders took place simultaneously with ACLF. Missouri sent a full delegation (not every state did!) and I was inspired by the stories of Missouri’s constituents – in every way possible, they represent the breadth, depth and diversity of our specialty!

I have found my experience thus far to be both instructive and humbling. I pledge to listen to the successes and challenges our members face over my coming two years on the Board. I encourage our members to engage at the state level and to consider opportunities for service or leadership within MAFP or partner organizations. I will work to grow as President in the coming year and thank you for the chance to be your representative.

ANNUAL REPORTS

Jamie Ulbrich, MD, FAAFP, Vice President

I

am a solo practice family physician from Marshall, Missouri. I have been in private practice for over 20 years. In the trenches so to speak, I did operative and non-operative obstetrical deliveries for 10 years, performed procedural family medicine including scopes until last year, and now practice outpatient family medicine including nursing home visits. My greatest assets are my wonderful wife, three children (two in high school and one in college) along with an excellent office staff at Ulbrich Family Medicine, LLC. I tell you all of this to let you know that I am both humbled and privileged to be a part of the MAFP leadership, and that I am hoping to get to know and develop relationships with as many members as possible in the next few years.

It has been a very busy year so far. I had the privilege of representing the MAFP at the 2018 Multi-State Forum held February of this year in Dallas. It was interesting to learn of the commonality of struggles among the 10 states present at the meeting. Shawn Martin, from the AAFP presented some payment reform models, advocacy efforts and discussed some of

"The late Mike Wulfers, MD, once told me that when you get and stay involved with the MAFP, you are not part of the problem, but part of the solution." the administrative burdens we can all relate to.

Maintenance of Certification was also discussed.

This was near and dear to my heart as I had the opportunity to sit for the MOC exam recently. It also gave us a chance to learn what seemed to be working in some states when each state had the opportunity to discuss their “best practices.”

Advocacy Day in February had a great turnout, but we would not be upset if we could see more physicians make the trip next year; there will be great company and free food! Advocacy 101, a primer on the legislative process as well as updates on the most important issues was held the night before, and followed the next morning with a breakfast briefing and a trip to the Capitol to meet with representatives and senators. A physical presence really demonstrates to our elected officials how important issues are to us. I promise you other professions are showing up to voice their opinions.

We have hired RJ Scherr and Associates this year as our lobbyist group. They were selected among several lobbying groups and I think you will be very happy with their expertise and insight into the legislative process. I would be remiss if I did not give a heartfelt thank you to Pat Strader and tell her how much we will miss her and appreciate her years of service to our academy. She worked tirelessly for us and taught me Advocacy 101 several times over. Thanks Pat! We at the MAFP want you to know that we are representing you both at the state and national level in all aspects of family medicine. If you are not a member of the academy, we would like to know why and what we could do to convince you to become an active member. If you have views that either support or oppose that of the MAFP we would like to know so we can address everyone’s concerns.

I accepted this position last year as Vice President of the MAFP after much prayer and reflection. I believe in the mission of the MAFP: “The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.” All members are welcome to attend our board meetings, where we have open discussions about relevant issues and all voices are heard. Things don’t always go as I would like them to, but in the end, I and the other board members feel we come out with the best decisions for the MAFP. The late Mike Wulfers, MD, once told me that when you get and stay involved with the MAFP, you are not part of the problem, but part of the solution. Thanks Mike. I’ll take your advice…

MO-AFP.ORG 7

ANNUAL REPORTS

Jim Stevermer, MD, MSPH, FAAFP, Outgoing Secretary-Treasurer

T

he financial stability of the Missouri Academy of Family Physicians remains sound, and we appear to have more than adequate reserves to sustain the Academy for the foreseeable future.

As of the end of the first quarter 2018, we had assets greater than three years of budgeted expenses. We are investing more in strategic areas, leading to minor budgeted deficits, however continued member support, as well as strong markets, have led to increased reserves.

Because of the cyclic and intermittent nature of our income and expenses, it’s a bit challenging to evaluate our actual flows against budget at this time of the year. However, our income and expenses remain consistent with past years. We have the resources to continue to invest in areas that will move our mission forward.

Resident Reports

Alicia Brooks, MD, St. Louis University, Resident Director

Ann Lottes, MD, Mercy Family Medicine, Alternate Resident Director

Cox Family Medicine Residency, Springfield, MO • Aaron R. Buzard, MD, MPH — Outpatient, Banner Health, Loveland, CO • Blake A. Fulks, MD — Hospitalist, CoxHealth Center, Branson, MO • Meghan E. Guthrie, MD — Outpatient, CoxHealth Medical Mile Clinic, Springfield, MO • Shannon N. Marsden, MD — Outpatient, Ferrell-Duncan Clinic, Springfield, MO • Caitlin S. Schmitt, DO — Outpatient, Barnes Jewish “Progress West Hospital,” O’Fallon, MO • Kenneth F. Starnes, MD — Emergency Medicine, Ozark Medical Center, Clinton, AR • Lisa S. Trask, DO — Currently interviewing • Sarah A. Williams, MD — Outpatient, Houston, MO 8

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

Mercy Family Medicine Residency, St. Louis, MO • Cherry Cockrell, MD — Outpatient, Mercy Clinic Family Medicine Maryland Heights, MO • Sally Kurz, MD — Currently Interviewing, Planning to join an academic program in Texas • Daniel O'Loughlin, DO, MPH, Sports Med Fellowship, Utah Valley Sports Medicine Fellowship Provo, UT • Jeremy Oliver, DO — Outpatient, Mercy Clinic Family Medicine Clayton-Clarkson, St. Louis, MO • Brett Warden, DO — Outpatient, Honor Health, Phoenix, AZ • Mark Zacharjasz, MD — Outpatient, Mahaska Health Partnership, Oskaloosa, IA

ANNUAL REPORTS

Research Family Medicine Residency, Kansas City, MO • Syed Faisal Ali, MD — Hospitalist, Kansas City, MO • Nathan Boehr, DO — Hospice and Palliative Medicine Fellowship, Kansas University • Chris Chappell, DO — Hospitalist, St. Louis, MO • Edward Christiansen, MD — TBA, Outpatient with OB, Olathe, KS or Bolivar, MO • Dianne Elledge, DO — TBA, Austin, TX • Christopher Fotopoulos, DO — TBA, Hospitalist • Georgina Green, MD — Outpatient (with OB), Paola, KS • Anna Hanson, MD — Outpatient, Kansas City, KS • Joanita Idicula, MD — Outpatient, Mississauga, Ontario, Canada • Kendall Johnson, DO — Hospitalist, Kansas City, MO • Robert Kreikemeier, DO — Hospitalist, Topeka, KS • Tommel Samani, MD — Hospitalist, Blue Springs, MO Saint Louis University Family and Community Medicine Residency, St. Louis, MO • Alicia Brooks, MD — Outpatient, Novant Health Salem Family Medicine, Winston Salem, NC • Michael Donovan, MD — Outpatient/ Academics, John C. Murphy Clinic, SLU, St. Louis, MO • Michelle Hall, MD — Outpatient, Heart of Florida Regional Medical Center, Davenport, FL • Jared Henrichs, MD — Outpatient, SSM Health Group, Webster Groves, MO • Joseph Moleski, DO — Hospitalist, St. Clare Hospitalist Group, St. Clare Hospital, Fenton, MO • Lauren Beal, DO — Outpatient, St. Anthony’s Family Medicine, Mercy Medical Group, Kirkwood, MO University of Missouri Family and Community Medicine, Columbia, MO • Chase Beliles, MD — Prime Care Physicians, owned by Graves-Gilbert Clinic, Bowling Green, KY • Shari Chang, MD — Practice in Springfield, MO • Krystal Foster, MD — University of Missouri Department of Family and Community Medicine, Faculty, Columbia, MO • Patrick Granneman, DO — Mercy Clinic, Ozark, MO

• • • • • • • •

Andrew Hinojosa, MD — UT Health Science San Antonio, Palliative Care Fellowship, TX Rebecca Hogg, MD — Practice in Jefferson City, MO Sarah Kirchhoff, MD — Rural Practice in clinic owned by Western Missouri Medical Center in Warrensburg/Concordia, MO Katie Martinez, MD — Avera Family Physicians, Aberdeen, SD Andrew Peterson, MD — Rural Practice in Illinois Timothy Ratliff, DO — University of Arkansas, Sports Medicine Fellowship, AK Drew Satterfield, DO — Rural Practice in Cape Girardeau and Dexter, MO James Tucker, DO — Rural Practice in Hannibal, MO

UMKC Truman Medical Center Lakewood, Kansas City, MO • Noushin Ansari, MD — Neurology Residency, Kansas City, MO • Chadwick Byle, MD — Sports Medicine Fellowship, Kansas City, MO • Jennifer Cabral, MD — Kaiser, Antioch, CA • Cassandra From, DO — Docs Who Care, Kansas City, MO • Ashley Hall, DO — Private Practice, Salt Lake City, UT • Maaroof Islam, MD — Saint Louis, MO • Caroline Martin, DO — Private Practice, Overland Park, KS • Kevin Munger, DO — Sports Medicine Fellowship, Kansas City, MO • Aaron Neisen, DO — Docs Who Care, Kansas City, MO • Theresa Nguyen, DO — College Park Family Care Center, Overland Park, KS • Jessica Richter, DO — Part time private practice at College Park Family Care Center, Overland Park, KS. Part time at FQHC-look alike clinic (free clinic), Hope Family Care Center, Kansas City, MO • Jacob Shepherd, MD — Active Duty United States Air Force Family Physician, Whiteman Airforce Base, Warrensburg, MO • Gretchen Stokes, MD — College Park Family Care Center, Overland Park, KS • Ryan Stokes, MD — Swope Central, Kansas City, MO

MO-AFP.ORG 9

ANNUAL REPORTS

Student Reports

John Heafner, Student, St. Louis University, Student Director

A. T. Still University of Health Sciences: Osteopathic Medical School, Kirksville, MO • No report.

Kansas City University of Medicine and Biosciences, Kansas City, MO • No report.

St. Louis University School of Medicine, St. Louis, MO • Student population: 720 • Students involved in FMIG: We consistently have about 30 students attend each event. We have recruited 61 students to join AAFP from the SLUSOM community.

• Goals: Increase awareness/interest in family medicine and primary care by serving the students, the institution, the community, and anyone in need.

• Events held this year: 'What is Family Medicine?' Introduction Talk, Family Medicine Residency Fair, M1 Procedure Night, Procedure Night at Mercy, Undergrad Procedure Night, Missouri Foundation for Health Talk, Undergrad Procedure Night, Family Medicine Match Panel.

• Future events planned: Residency Fair (September 5, 2018), Procedure Night with SLU FM Residency Program.

• Students matched into family medicine: 21 • Executive board members: • President: Anna Priddy (anna.priddy@ health.slu.edu) • Financial Officer: Matt Cormier (matt. cormier@health.slu.edu) • Operations Officers: Cornita Cannon (cornita.cannon@health.slu.edu) and Robert Turlington (robert.turlington@ health.slu.edu) • Faculty Advisor: Matthew Breeden, MD (matthew.breeden@health.slu.edu)

10

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

Mimi Liu, Student, St. Louis University, Alternate Student Director

University of Missouri School of Medicine, Columbia, MO • Student population: 436 • Students involved in FMIG: n/a • Goals: Top priority right now is engaging M1 students and finding ways to make them active in FMIG. • Events held this year: Helpful hints for MS year at the Heidelberg; Welcome Back Fiesta; Ronald McDonald House Dinners; Grand Rounds Lunches; Fall Dinner Forum.

• Future events planned: Residency Fair, Doctors Back to School, Tar Wars, Ready Set Fit, and Spring Dinner Forum.

• Students applying to family medicine this year: Five solely, many are dual applying. No update for total family medicine match.

• Student contacts: Main Campus Co-chairs: • Kane Laks, Lindsay Koerperich, Dalton Lohsandt • Springfield FMIG Co-chair: Aundria Eoff • Secretary: Jordan Cruz • AAFP Liaison: Liga Blyholder • RMH Coordinator: Tori Dahmer (main campus), Aundria Eoff (Springfield) • Harbor House Coordinator: Shanon Luke • Advisor: Amelia Frank, MD (frankae@ health.missouri.edu) University of Missouri-Kansas City School of Medicine • Student population: 600-650 (total six year BA/ MD program) • Students involved in FMIG: 10 per meeting • Goals: To introduce students to family medicine and the opportunities available within the field. To provide contacts and resources to those interested in family medicine. To educate students in the community about healthy living through sports physical events.

ANNUAL REPORTS •

• • •

Events held this year: Clinical skills workshop, Sports physicals events, RBI sports physicals Event with the Boys and Girls Club, Strolling through the Match Post Match Panel.

Future events planned: Sports Physicals Event for the community in July.

Students matched into family medicine: Eight Student contacts: • Seenu Abraham (savhd@mail.umkc.edu), Columbine Che (cncd49@mail.umkc.edu), Nymisha Rao (nry74@mail.umkc.edu), Kyla Mahone (km824@mail.umkc.edu), Emma Connelly (emcmv4@mail.umkc.edu) • Advisor: Dr. Miranda Huffman (huffmanmm@umkc.edu)

Washington University School of Medicine, St. Louis, MO • Student population: 400 MD students plus 2025 MTSP students per class.

• Students involved in FMIG: 150 students on listserv, 30 active members.

• Goals: to increase exposure to primary care related fields at a center that is very tertiary/ quaternary care driven and to provide students interested in primary care fields or in family medicine with community mentors at nearby institutions such as Mercy and SLU who have family medicine residencies. Since Wash U does not have a family medicine program, SLU and Mercy provide essential support in helping students match into family medicine and gain exposure to the field.

• Events held this year: This year, we have held an introductory lunch talk, a procedure night and lunch talk as a part of Primary Care Week (which is hosted in conjunction with AMSA at our institution), and a few networking dinners with local family medicine doctors.

• Future events planned: We will be hosting a panel and networking dinner with the recently matched family medicine fourth year students and a summer picnic that is hosted by some of the physicians in the area for anyone in town over the summer.

• Students matched into family medicine: Five • Student contacts: • Sean Terada (seanterada@wustl.edu), Amisha Parikh (aparikh@wustl.edu), Shariq Khan (skhan29@wustl.edu) • Advisor: Dr. Phillip Asaro (asarop@ wustl.edu)

Part Time Physicians Wanted!

Clinical Research Professionals is a St. Louisbased privately owned clinical research company looking for retired physicians who want to keep their hands and mind in the game. The position is part-time, hours are flexible and the environment and staff are awesome! No hassles of hospital systems, physician groups or medical insurance bureaucracy, just simple and rewarding doctorpatient interaction.

The ideal candidate is a physician winding down his/her clinical practice or already retired:

w Looking for something fun and engaging to do w Interested in research w Who would like to generate some income to support their hobbies Responsibilities include:

w Supporting Principal Investigator w Patient care, including physical examinations, laboratory result assessments, ecg assessments, study enrollment criteria review based on patient medical records or self-reported medical history, study assessments

w Reviewing labs and diagnostic results We provide all necessary resources including:

w Malpractice liability insurance w State of the art research facility w Fun interactive environment w Flexible pay and hours No previous research experience required.

Interested?

Please contact Candace Grasse at 636-220-1200.

www.clinicalresearchprofessionals.net MO-AFP.ORG 11

>

opioid

) >

epidemic In the late 1990s

, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relievers. Health care providers began to prescribe them at greater rates. Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive.

In 2017 The U.S. Department of Health and Human Services declared a public health emergency.

The following articles address a wide array of topics pertaining to opioid abuse, addiction, overdose, recovery support services, and how we as a society can address this painful epidemic...

The Primary Care Approach

"

Kurt Bravata, MD, Buffalo, MO

O

Urge Congress to include two important provisions to address the opioid crisis: Tell Congress to support NIH research and PDMP improvements in any final opioid misuse legislation. Visit: https://bit.ly/2tKn4HZ On June 22, 2018, The American Society of Addiction Medicine (ASAM) announced hearty applause for the House of Representatives bipartisan action to pass the Substance UseDisorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (HR 6), the Overdose Prevention and Patient Safety (OPPS) Act (HR 6082), and the IMD Care Act (HR 5797). This sweeping legislative package makes important reforms on a range of issues including improving patient care coordination and safety, expanding the addiction treatment workforce, expanding access to addiction treatment, enhancing peer support specialist programs, ensuring the provision of evidence-based treatment, and improving provider education. Included in discussion points provided by the AAFP Office of Government Relations, according to U.S. Department of Health and Human Services (HHS) 2016 data, 11.6 million individuals misused prescription pain medications and 42,249 people died from opioid overdoses (116 people/day) in 2016. The economic cost of the opioids epidemic was estimated at $504 billion that year. According to the TIME National Institutes of Drug Abuse (NIDA) analyses, 92 million individuals were prescribed opioids in 2015 and fewer than 13% abused them. According to a 2015 Annals of Internal Medicine report, economic disadvantage and behavioral health problems are associated with opioid misuse. A New England Journal of Medicine report indicates that 30% of Americans experience either acute or chronic pain and 40% of older adults experience pain.

In confronting this crisis, AAFP has clearly

)

)

n May 21st – 22nd, I had the opportunity and privilege to serve as a key contact for the Missouri Academy of Family Physicians (MAFP) on behalf of the American Academy of Family Physicians (AAFP) at the Family Medicine Advocacy Summit (FMAS) in Washington, DC. The event was attended by nearly 300 family physician delegates from around the United States who had come together to advocate regarding pertinent health care issues on the House and Senate legislative agenda.

It was no surprise that high on the list of priorities were bills regarding the opioid abuse crisis. In the Senate and House, we had the ACE Research Act (S. 2406 and HR 5002) which seeks to expand chronic pain research and increase access to substance abuse treatment through Medicaid and Medicare.

Limited to the House was HR 5812 which focuses on improving state prescription drug monitoring programs (PDMPs). These bills would build on the Comprehensive Addiction and Recovery Act of 2016 (CARA, PL 114-198).

Additionally, in Missouri, we have the Omnibus Pharmacy Bill (SB 826) which applies a sevenday opioid prescription limit for patients new to a provider, with some exceptions, and includes a provision for a drug takeback program at retail locations.

Both HR 5002 and HR 5812 passed by voice vote in the House on June 12th, and AAFP is urging its members to speak out by encouraging our representatives to ensure that the final bill passes Congress with provisions supporting National Institutes of Health (NIH) research and improved prescription drug monitoring programs (PDMPs).

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

"

14

The opioid crisis is the worst addiction epidemic in American history.

Drug overdoses kill more than 64,000 people per year, and the nation’s life expectancy has fallen for two years in a row.

stated their understanding that the nation’s opioids crisis intersects with a range of health issues that family physicians encounter in their practices: pain management, health care access, substance abuse treatment, and socioeconomics. The AAFP also believes studies and best practices should consider the needs of vulnerable populations who are at higher risk for under-treatment of pain and/or for opioid misuse.

Family physicians are on the front lines of addressing the opioid abuse crisis and the AAFP reports that in 2017 their members completed more than 157,218 continuing medical education credits on the topic of opioid abuse. As a member of the AMA Task Force to Reduce Opioid Abuse, the AAFP has maintained and reaffirmed their commitment to providing resources for family physicians and to advocate for policies promoting prevention, research, health care coordination, and treatment access. This is supported by their own position paper, Opioid Prescribing and Opioid Misuse: A Public Health Crisis, which prioritizes support to expand research into the management of chronic pain, as well as methods to better identify and manage opioid misuse. (https:// www.end-opioid-epidemic.org/) (https://www.aafp. org/about/policies/all/pain-management-opioid.html) On February 22, 2018, TIME magazine released a special issue reporting on the opioid crisis titled, The Opioid Diaries. This article was a photojournalism piece chronicling the haunting images of the opioid epidemic from around the country. This glimpse into the underground world of vice and venom was shocking to many, but it should not be a surprise, especially to those of us in the medical field. The crisis has been building for the last three decades, to the point that, as TIME reported, “The opioid crisis is the worst addiction epidemic in American history. Drug overdoses kill more than 64,000 people per year, and the nation’s life expectancy has fallen for two years in a row.” (http://time.com/james-nachtwey-opioidaddiction-america/)

So, what are we as primary care physicians going to do about this mounting problem which is staring us in the face? If you are like me, you didn’t go into family medicine to become an addictionologist, nor did you intend to spend the bulk of your time treating chronic pain. Yet I, like many of you, am finding myself pressed into a corner where the only option is to take the bull by the horns and attempt to make a real difference, if not out of passion, then at least out of necessity. However, for me it seems that passion and necessity have met square in the middle.

Unfortunately, despite our efforts to make a difference, there is no doubt that one can easily fall

into certain prescribing patterns that either by way of past miseducation on chronic pain management, neglect, disinterest, or simply oversight, contribute directly or indirectly to the opioid abuse crisis. The facts are truly startling: • Relaxed statutes on prescribing opioids in the late 1990s encouraged widespread opioid use.

• By 2012, more than 250 million opioid prescriptions were dispensed in the US, nearly 50% through primary care specialties.1 • The rate of opioid-related overdose deaths increased 200% in the US from 2000-2014.2 • More than 100,000 people in the US have died, directly or indirectly, from opioid-related causes between 1999 and 2010.3 References: 1 Franklin GM. Neurology 2014;83:1277-84; 2 Levy B, et.al.

Am J Prev Med 2015;49:409-13; 3 Rudd RA, et.al. MMWR Morb Mortal Wkly Rep 2016; 64:1378-82; 4 United Nations, International Narcotics Control Board. Report of the International Narcotics Control Board for 2008; 2009; 5 Jones CM, et.al. JAMA 2013;309:657-59; 6 Califf RM, et.al. N Engl J Med 2016; Feb 4: Epub ahead of print.

Anyone who spends any length of time seeing patients in the primary care setting knows that the problem of chronic pain isn’t going anywhere. This is compounded by a myriad of other complicating health, psychosocial, and economic factors which keep patients in a cycle of emotional and physical pain and chronic disability. The stats on this are quite astounding: • 1 in 4 US adults has suffered with pain for a 24-hr period.1 • Affects more Americans than cancer, diabetes, and heart disease combined.2 • Costs $560-635 billion annually.2,3 • The prevalence of reported pain has increased steadily across all demographic groups.3 References: 3 CDC. Health, United States, 2006 with Chartbook on Trends in the Health of Americans. 2006; 2 National Institute of Nursing Research. Fact Sheet--Pain Management. 2010; 3 Institute of Medicine.

Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011.

It seems that just about anyone you talk to, both lay and professional people, have stories about family members, friends, or associates who suffer from chronic pain or opioid dependence. The opioid abuse crisis is touching nearly everyone and the world is awake to the problem. As a consequence, legislators are taking notice and are feeling pressure from their constituents to show that they are doing something about this epidemic.

Health care providers are not immune from scrutiny or culpability when it comes to the opioid abuse crisis. In fact, if you are a physician who prescribes opioids, you may have recently received a version of the following letter from the Missouri Department of Social Services on one or more of your Medicaid patients: (see letter on following page)

MO-AFP.ORG 15

*

You are being contacted because your opioid prescribing activity was flagged as it relates to the following Quality Indicators™.

• Use of Buprenorphine with another Opioid • Use of Buprenorphine with a Benzodiazepine • Use of Opioids for 60 or More Days with a Diagnosis Suggesting Opioid, Alcohol, or other Substance Abuse in the Last Year • Use of Opioids for 60 or More Days with Two or More Diagnosis of Malingering, Somatization, or Factitious Disorder • Use of Opioids for 60 or More Days in Absence of a Diagnosis Supporting Chronic Use • Use of Opioids for 60 or More Days in Absence of a Diagnosis Supporting Chronic Use (Under 18 Years) Providers have 20 business days from the date of this letter to respond. A feedback form is included to facilitate provider responses.

Providers that fail to response may be referred to the Bureau of Narcotics and Dangerous Drugs.

Even if you have not yet received one of these letters, the simple thought of doing so could easily be anxiety producing. Your palpitations may be justified, because in fact, our medical judgement is being questioned by this initiative. Indeed, our licenses could be on the line here. For sure, there are those who would say that it is high-time that physicians experience a little more pause before prescribing opioids and that no one should be exempt from potential implication for their potential contribution to the opioid abuse crisis.

However, as physicians, this is a strange place to be.

We are particularly uncomfortable being in the hot-seat, so-to-speak. Not to say that anyone relishes having an accusing finger pointed at them, but we as medical professionals tend to think of ourselves as the good-guy.

After-all, we took an oath to, “First, do no harm.”

So, why are many well-intentioned family physicians, most of whom went to medical school with the express purpose of helping people and making a positive difference in the world, now receiving such disconcerting letters. Well, to get our answers, let’s go straight to the source.

On March 5, 2018, the following news bulletin was released from the office of former Missouri Governor, Eric Greitens. (https://governor.mo.gov/news/archive/ governor-greitens-announces-crackdown-medicaidproviders-overprescribing-opioids)

'Governor Greitens Announces Crackdown on Medicaid Providers Overprescribing Opioids'

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

The tone of the article continued in the same stern manner as did the title: “Today, Governor Greitens announced a new effort to protect Missourians from opioid addiction by cracking down on providers who over-prescribe powerful drugs.

Medicaid providers who refuse to comply with Centers for Disease Control and Prevention guidelines will be held accountable."

Statement from former Governor, Eric Greitens: “Too often, Missourians seeking real help are getting hooked on dangerous drugs that threaten their lives. We trust doctors to give us sound advice, and most of them do.

Family doctors in communities across the state take good care of people and save lives. Still, in every system there are bad actors who put greed, ease, or profit ahead of their mission to help people.

There are prescribers manipulating the system and creating or feeding dangerous habits. Last year, there were more than 1.2 million opioid prescriptions in our Medicaid system alone—sometimes destroying the lives and families of our neighbors.

Today we announced a new initiative that will hold providers in the Medicaid system who prescribe too many opioids, and refuse to change their ways, accountable for their actions. The people who push unnecessary, expensive, and powerful prescriptions to Missourians are ruining lives, and we’re working to stop it. We’re cracking down on this dangerous behavior within the Medicaid system to keep patients safe and protect our communities from the opioid epidemic that threatens so many families.”

Concurrently, with this legislative memo came a letter or email to all MO HealthNet Providers announcing the above opioid intervention program as well as notification that as of March 6, 2018, MO HealthNet would start implementing the following revisions to the short-acting opioid and short-acting combination: • Initial Rx for Opioid-Naïve participants will be limited to 50 MME’s • Acute opioid therapy will be limited to 60 days AND • Acute opioid therapy is not to exceed 90 MME’s • Opioid therapy > 60 days will be considered Chronic and will require a PA • Chronic Non-Malignant Pain (CNMP) diagnoses have been streamlined AND • PA for CNMP will be limited to approved diagnoses only For more information about the OPI Program, please reference the MO HealthNet provider OPI (https://dss.mo.gov/mhd/providers/opiprogram.htm)

"

"

One of my worries is that many physicians will resort to cutting off their pain patients from opioids, dismiss them from their practice, or attempt to offload them to the increasingly diminishing supply of opioid prescribing pain management specialists.

It can be discouraging when family physicians, who are on the first line of care for Medicaid and Medicare patients, are lumped in as part of the problem; when the reality is that most physicians who liberally prescribed opioids during the 90s and early 2000s were just following the consensus guidelines for opioid prescribing set out by the American Pain Society (APS)-- including pain as the 5th vital sign. (http://americanpainsociety.org/ uploads/education/section_2.pdf) This idea was reinforced in 2001, when the Joint Commission rolled out its Pain Management Standards (https://www.ncbi.nlm.nih.gov/ pubmed/12024631) which required health care providers to ask every patient about their pain, as a response to the general perception at the time that pain was being undertreated. The argument being that chronic unrelieved pain was costing the health care system approximately $100 billion annually. Purdue Pharma, already capitalizing on this trend, was marketing OxyContin, their longacting version of the opioid oxycodone, as being less-likely to cause abuse and addiction than shorter acting painkillers like Percocet. Despite the fact that the Food and Drug Administration (FDA) allowed

Purdue Pharma to make this claim as early as 1996, by 2003 the U.S. Justice Department began investigating the drug company for intentionally misleading physicians and the American public. In 2007, Purdue Pharma pleaded guilty to a felony charge of “misbranding” OxyContin while marketing the drug by misrepresenting, among other things, its risk of addiction and potential to be abused. By May 2018, a massive class action lawsuit against Purdue Pharma was well underway, involving 22 U.S. states and Puerto Rico, with other states to follow.

Now that we are facing the formidable consequences of the unforeseen tidal wave of opioid misuse, dependence, and addiction, which has swept across our nation in the last two decades, many physicians are rising to the occasion to address the opioid abuse crisis. I wrote about my initial foray into substance abuse treatment (using oral Naltrexone and Vivitrol) in the primary care setting in the AAFP Fresh Perspectives Blog article titled Fresh Approach Turns Substance Abuse Challenges into Triumphs in 2015. In 2016, I obtained my Drug Addiction Treatment Act of 2000 (DATA 2000) Waiver for prescribing buprenorphine products like Suboxone in the medication-assisted

MO-AFP.ORG 17

"

If anyone can lead the charge to turn the tide of opioid misuse and abuse in this country, I am certain family physicians are more than up to the challenge.

treatment (MAT) of opioid use disorder and addiction.

MAT for substance use disorders (SUDs) is now a regular and growing part of my practice. I know that I am not alone in this and it is my belief that many primary care physicians, like me, see themselves as a key part of the solution in addressing this epidemic.

Like many other physicians in Missouri who work diligently every day to achieve a delicate balance of risk vs. benefit for their patients, I found the tone and delivery of the new MO HealthNet Opioid Intervention Program to be somewhat disheartening. My main concern is that there seems to be no clear provision made to distinguish the bad-actors from the majority of well-meaning good-acting physicians who work every day to carefully manage the health and pain of their patients, tailoring care to each individual patient’s needs, while doing their best to adhere to prescribed guidelines. This was a concern I had in March 2016 when the CDC released its new Guidelines on Opioid Prescribing; because of which I wrote an AAFP Fresh Perspectives blog article titled Insurance Hurdles Add Challenge to Treating Pain in which I expressed cautious optimism, tempered by concern that universal pain management guidelines could create new legal pressures and liabilities for physicians without providing the necessary tools to manage the problem of chronic pain; nor reducing the insurance obstacles which make abuse deterrent pain management so difficult. One of my worries is that many physicians will resort to cutting off their pain patients from opioids, dismiss them from their practice, or attempt to off-load them to the increasingly diminishing supply of opioid prescribing pain management specialists. The truth is if primary care and pain management practices become an uninviting inhospitable place for opioid dependent patients, there will be no safety net for them and many will inevitably resort to finding their drugs on the street where they are easily accessible, and in many cases, cheaper. This means that our aggressive attempts to fix the opioid prescription crisis, may inadvertently make the illicit opioid abuse epidemic even worse, at least in the short term, before it gets better.

I know I am not the only physician with such concerns. On March 13, 2018, the Missouri Academy of Family Physicians (MAFP) sent an open letter (https://www.mo-afp.org/wp-content/uploads/ Greitens-Opioid-Letter-Final.pdf) addressed to former Governor Greitens, Department of Social Services (DSS), Department of Mental Health (DMH), and Department of Health and Senior Services (DHSS), in which they expressed their strong concerns with any efforts by these agencies to enforce or codify the CDC

18

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

Guideline as written. The letter affirmed Missouri family physicians' commitment to responsible opioid prescribing in consultation with the CDC’s opioid prescribing guidelines. Written by MAFP President, Dr. Mark Schabbing, MD, this letter went on to eloquently and comprehensively address concerns held by the majority of family physicians, emphasizing the importance of maintaining the sanctity of the doctorpatient relationship, and the error of turning guidelines into law at the risk of undermining a physician’s discretion to make case-appropriate medical decisions, thus disrupting medical care and adding regulatory burden without offering any real solutions. After all, as the MAFP letter pointed out, the CDC guidelines clearly state: “Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context. The recommendations in the Guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.” (https://www.cdc.gov/mmwr/ volumes/65/rr/rr6501e1.htm) With all this added pressure to comply with CDC opioid prescribing guidelines, we are the only state in the nation without a state-wide prescription drug monitoring system (PDMP). This is despite the fact that on July 13, 2016 Missouri’s Governor, Jay Nixon and 43 other governors signed a Compact to Fight Opioid Addiction which included a commitment to integrate PDMPs into electronic health records. The topic of the PDMP has sparked a lot of passionate debate in Missouri over citizen’s privacy rights, individual autonomy, and the purported conflicting goal of monitoring and restricting patients access to prescription narcotics. Although the jury is still out as to the actual benefit of PDMPs, there is wide consensus in the medical community that having one more tool in our arsenal to reduce patient risks and protect physician liability is a good thing. Currently, pharmacies have the option to opt-in to the St. Louis PDMP county-by-county.

There are over 50 counties in Missouri with some level of participation in the St. Louis PDMP. As physicians, it is our job to use as many tools as possible at our disposal to provide the most comprehensive and optimized care for our patients.

However, as people of science who are trained to

base our decisions on rigorously proven highly distilled evidence, it is our prerogative and mandate to use our best judgement when choosing when, where, and how to use the guidelines and resources available to us. When it comes to the PDMP or Opioid Prescription Intervention Program (OPIP) a healthy dose of scrutiny and skepticism may be warranted and even desirable as we approach the challenging and complex process of practice change and improvement. This must be tempered with an open mind and willingness to go where the evidence leads us.

But, our legislators must be held to the same standard, and it would be disingenuous of them to firmly fix the blame for the opioid abuse and misuse crisis on physicians and pharmaceutical companies, when current trends show that a large percentage of the opioid-related overdoses and deaths are linked to illicitly produced and obtained Fentanyl and Carfentanil.

It would be incredibly detrimental to population health if physicians relinquish primary care management of opioid prescribing, putting their patient’s best interest on the line, because they can no longer justify the risk they are assuming by continuing to pain manage these high risk individuals. These psychosocially complex opioid dependent patients with multiple chronic pain-generating medical problems are exactly the type of patients who require close primary care management of the whole person. Yet, physicians like myself are being pressured to substitute their patientcentered case-based medical judgment for the goal of balancing patient satisfaction against provider risk management, in addition to the primary goal of promoting optimal patient health.

So clearly, family physicians need to be brought to the table to help develop guidelines, protocols, and legislation seeking to govern our clinical decision making, especially as it relates to opioid prescribing. There is a need to make our presence known and our voices heard. We cannot sit idly by and abdicate our decisionmaking responsibility, while law makers attempt to solve our side of the opioid abuse equation.

We need to educate our legislators and government officials about what we as family physicians are doing to address the problem and elicit their support for policies which help facilitate our ability to get this job done. Afterall, family physicians are leaders in primary care innovation and delivery. If anyone can lead the charge to turn the tide of opioid misuse and abuse in this country, I am certain family physicians are more than up to the challenge.

HELPFUL TOOLS FOR YOU SUBSTANCE USE SCREENING

SUBSTANCE USE RISK STRATIFICATION

SBIRT (Screening, Brief Intervention and Referral to Treatment )

Screener and Opioid Assessment for Patients in Pain [SOAPP®]

CAGE Questionnaire (Cut down, Annoyed, Guilty, Eye Opener)

Opioid Risk Tool (ORT)

AUDIT C (Alcohol Use Disorder Identification Test)

Pain Medication Questionnaire (PMQ)

DAST -10 (Drug Abuse Screening Test)

Prescription Drug Use Questionnaire patient version (PDUQP)

COMMON ABUSE DETERRENT OPIOIDS: Emebeda (12-24 hr Morphine + Naltrexone capsule) Butrans (7 day buprenorphine TD patch) Bellbuca (12 hr buprenorphine SL film) Zohydro ER (12 hr hydrocodone bitartrate capsule) Hysingla ER (24hr hydrocodone bitartrate tablet) Xtampza ER (12 hr Oxycodone capsule) Morphabond ER (1st single agent abuse deterrent ER morphine (12hr) BUPRENORPHINE PREPARATIONS: Belbuca (buprenorphine buccal film = agonist) Bunavail (buprenorphine/naloxone = agonist/antagonist) Buprenex (IV or IM buprenorphine) Butrans (7 day buprenorphine patch) Probuphine (6-month buprenorphine implant) Subutex (buprenorphine SL tablet) Suboxone (buprenorphine/naloxone SL film or tablet) Zubsolv (buprenorphine/naloxone SL tablet) Buprenorphine/Naloxone, generic equivalent of Suboxone, FDA approved June 14th 2018

CALCULATING TOTAL DAILY DOSE OF OPIOIDS FOR SAFER DOSAGE 50 MME/DAY:

90 MME/DAY:

• 50 mg of hydrocodone (10 tablets of hydrocodone/ acetaminophen 5/300) • 33 mg of oxycodone (2 tablets of oxycodone sustained-release 15 mg) • 12 mg of methadone ( <3 tablets of methadone 5 mg)

• 90 mg of hydrocodone (9 tablets of hydrocodone/ acetaminophen 10/325) • 60 mg of oxycodone (2 tablets of oxycodone sustained-release 30 mg) • 20 mg of methadone (4 tablets of methadone 5 mg)

OPIOID

(doses in mg/day except where noted)

MME/day CONVERSION FACTOR

Codeine

0.15

Fentanyl transdermal (in mcg/hr)

2.4

Hydrocodone

1

Hydromorphone

4

Methadone

-

1-20 mg/day

4

21-40 mg/day

8

41-60 mg/day

10

≥ 61-80 mg/day

12

Morphine

1

Oxycodone

1.5

Oxymorphone

3

*MME: Morphine mil equivalent

MORPHINE EQUIVALENT DOSE (MED) Opioid

Approximate Equianalgesic Dose*

Morphine (reference)

30 mg

Codeine

200 mg

Fentanyl transdermal

12.5 µg/hour

Hydrocodone

30 mg

Hydromorphone

7.5 mg

Oxycodone

20 mg

Oxymorphone

10 mg

*Use only for calculating daily morphine equivalent dose from all sources of opioids, not for converting from one opioid to another. *Sources: Franklin GM. Neurology 2014;83:1277-84; Washington State Agency Medical Directors. 2010. http://www.agencymeddirectors.wa.gov/files/opioidgdline.pdf

Compassion and

Every part of my being

cried in agony and only

)

)

twelve hours had passed since I

from me but it was not going to take my life. I made the decision to go to the hospital and beg for help.

I cannot recall much about my hospital stay.

Every minute felt like eternity. I remember crying out to every person who entered the room, “I am addicted to opioids and I am going to die. Please help me … I do not want to die!” I am sure that even the housekeeping staff heard my cries. Most importantly, God heard my cries for help and began to lay a path for my recovery.

After three days, I was visited by a family physician, Dr. Dan Vinson, who started me on a medication with the active ingredient buprenorphine. I had limited knowledge about the medication; I knew it was used to help people recover from opioids and that the brand name was commonly mispronounced. At the time, very few physicians prescribed it and the waiting lists for treatment ranged from six months to a year

20

I

had last used an

opioid.

knew that the withdrawals were only just beginning. An inescapable fear was closing in on me like the night terrors that haunted my sleep as a child. I prayed for sleep, a momentary escape from the pain, but I knew that it would not come.

As the restless anxiety coursed through my body, I kicked my legs to remove the blankets.

With beads of sweat forming on my chilled skin and tears streaming down my cheeks, I wanted to move but the pain was too much to bear. The familiar sadness that immobilized my spirit held me to the bed like the weight of a thousand pounds.

The stomach cramps were starting … slowly at first and progressively intensifying until the heaving left nothing for my body to eliminate. Enduring another moment in my body was inconceivable.

As I considered the seemingly endless days ahead, I knew that I could not withstand opioid withdrawal or obtain long-term recovery on my own. For lasting change, I needed help. The familiar voice inside urged me to escape, “You know what will make this all go away.” This time, however, the destructive consequences of using opioids had imbued me with a heartache that exceeded the present physical discomfort, and I was determined to find a way out.

With psychotherapy, counseling, and numerous trips to inpatient and outpatient treatment behind me, I was well acquainted with the traditional psychosocial model. I understood why I used opioids, logically; however, my thoughts were clouded by the immediacy of my torment and logic was elusive.

The one thing I knew for certain was that my addiction to opioids had taken nearly everything

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

or more. Nevertheless, Dr. Vinson found

space for me in his practice and for this I am forever grateful.

Many years have passed now and it is surreal to reflect on the past, particularly in light of the current paradigm shift toward the use of medications for the treatment of opioid use disorders (OUDs). Over the last decade, increased funding, advances in national and international research, advocacy, and education have transformed the views of medications for use in recovery to evidence-based, best practice.

Buprenorphine is now regarded as one of the primary medications for use in the medical treatment and maintenance of OUDs – a substance use disorder characterized as a chronic, progressive and life-threatening disease, similar to asthma or hypertension1. The amassed evidence shows that, in addition to its cost-effective public health benefits, the use of maintenance medications for management of OUDs, like buprenorphine, result in better treatment retention, lower risk of relapse and death2.

Initiatives to expand the knowledge base and improve outcomes for individuals with OUDs are progressing as we confront this preventable public health crisis. However, there are gaps to be filled. Access to treatment in urban and rural communities continues to be a stumbling block for many individuals trapped in the cycle of

"

Buprenorphine Saved My Life

References: 1 American Society of Addiction Medicine. (2014, November 7). Treating Opioid Addiction as a Chronic Disease.

2 National Institute on Drug Abuse. (2016). Effective Treatments for Opioid Addiction.

3 The Substance Abuse and Mental Health Services Administration. (2018, February15). Treatment Improvement Protocol (TIP) 63, Medications for Opioid Use Disorder.

He sat on the side of my hospital bed and with kindness and empathy he said, “I am willing to work with you if you are willing to work with me.” A family physician asking me to work with him was beyond anything I could comprehend. His willingness to see me as a person worth working with gave me the resolve I needed to do whatever it would take to fight my disease.

"

opioid addiction. Allocating funding for Certified Community Behavioral Health Clinics (CCBHCs), as well as city and county public health programs that offer medications like buprenorphine can improve access and availability for treatment3.

The role of family physicians cannot be underscored enough. Serving as the primary health care providers, family physicians are often the point of contact for patients in need of help.

Obtaining the waiver to become a buprenorphine prescriber and developing provider partnerships or networks can improve access to medications for treatment of OUDs3. Developing relationships with patients by asking open-ended questions about their lives and demonstrating compassion can open the door for conversations with patients who may be apprehensive about asking for help. These interactions have the potential to save lives.

Dr. Vinson, my family physician, who visited me in the hospital many years ago, approached me with more compassion than I believed I deserved. He explained that buprenorphine was not a magic pill. I would need to do the hard work to find recovery. As he sat on the side of my hospital bed, with kindness he said, “I am willing to work with you if you are willing to work with me.” A family physician asking me to work with him was beyond anything I could comprehend. His willingness to see me as a person worth working with gave me the resolve necessary to do whatever it took to fight my disease. I started buprenorphine treatment and as the clouds dissipated from my mind, I sought counseling, treatment, and support in the community. Over time, logical reasoning returned. Today, I am free from the bondage of opioids, one day at a time.

Brie Wagner graduated magna cum laude from Columbia College with a BA in Human Services. She will receive an MPA in December, 2018 from the Truman School of Public Affairs. As an advocate for buprenorphine and the treatment for SUDs, she shares her story with health care providers, students and legislators and serves on the board of directors for MO Recovery Network. She is also the mother of four amazing daughters.

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Injectable Extended-Release Naltrexone Effective for Opioid Use Disorder American Family Physician. 2018 Jun 15;97(12):819

C

linical Question

Is injectable extended-release naltrexone (Vivitrol) as effective as daily oral buprenorphine/naloxone (Suboxone) for preventing relapse in adults with opioid use disorder?

Bottom Line

Injectable extended-release naltrexone administered every four weeks is similar in efficacy to daily oral buprenorphine/naloxone for the treatment of opioid use disorder. Patients using extended-release naltrexone reported higher satisfaction with treatment and were more likely to recommend it to others. (Level of Evidence = 1b–)

Synopsis

The use of oral medications to treat opioid use disorder is fraught with low adherence and a high dropout rate. These investigators identified 159 adults, 18 to 60 years of age, who met standard diagnostic criteria for opioid use disorder. Study participants randomly received (concealed allocation assignment) oral buprenorphine/ naloxone, 4 to 24 mg per day administered in a controlled environment, or intramuscular extended-release naltrexone, 380 mg every four weeks. Although individuals who assessed outcomes were not masked to treatment group assignments, individual primary outcomes were objective and minimally prone to biased reporting (e.g., study retention rate, number of days with negative urine drug tests, number of days of heroin and other illicit opioid use). Missing urine drug tests was considered positive for opioids. Complete follow-up occurred for 66% of participants at 12 weeks. More individuals in the daily buprenorphine/naloxone group failed to complete follow-up than in the extended-release naltrexone group (23 vs. 15, respectively).

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

Using intention-to-treat analysis, no significant differences occurred between the extended-release naltrexone group and the oral buprenorphine/naloxone group in study retention time, negative opioid urine drug tests, and days of heroin and other illicit opioid use. Similarly, no group differences occurred in the use of amphetamines, cocaine, alcohol, cannabis, or injected drugs. Significantly more patients in the extended-release naltrexone group had a reduction in days of benzodiazepine use and higher reported satisfaction, and significantly more were likely to recommend their treatment to others. No significant differences occurred in dropout rates due to adverse events.

• Study design: Randomized controlled trial (single-blinded) • Funding source: Foundation • Allocation: Concealed • Setting: Outpatient (specialty) References: Tanum L, Solli KK, Latif ZE, et al. Effectiveness of injectable extended-release naltrexone vs daily buprenorphinenaloxone for opioid dependence: A randomized clinical noninferiority trial. JAMA Psychiatry. 2017;74(12):1197–1205.

David C. Slawson, MD Professor of Family Medicine University of North Carolina at Chapel Hill Chapel Hill, N.C. POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see https://www.essentialevidenceplus.com/product/ebm_loe. cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb. This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of POEMs published in AFP is available at http:// www.aafp.org/afp/poems.

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The Missouri Opioid State Targeted Response (Opioid STR) project

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RECOVERY

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TREATMENT

TRAININGS

RESOURCES

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PREVENTION

EVENTS

missouriopioidstr.org

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We must help everyone see that addiction is not a character flaw — it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.

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he Missouri Opioid State Targeted Response (Opioid STR) project will expand access to integrated prevention, treatment, and recovery support services for individuals with opioid use disorder (OUD) throughout the state. Primary focus will be on rigorous, multidisciplinary provider training and education on evidence-based treatment services to uninsured individuals with OUD presenting for care within state-funded programs. Primary prevention activities will center around increased awareness and decreased availability of opioids, led by local agencies in high risk areas. Prevention of overdose deaths will be accomplished through training clinical providers and at-risk individuals on

— Former Surgeon General, Dr. Vivek Murthy

Overdose Education and Naloxone Distribution practices, and providing telemedicine didactic and consultation services to primary care providers treating chronic pain.

Recovery support services will be provided in the form of Recovery Community Centers, recovery housing, and recovery management checkups, all delivered with a focus on peer engagement. The State of Missouri Department of Mental Health (DMH) is leading the project, with administration, implementation, and evaluation activities provided by the Missouri Institute of Mental Health (MIMH) – University of Missouri, St. Louis, as well as health care agencies, additional academic institutions, and content experts throughout the state.

SEE PAGE 28 FOR SOME QUICK STATISTICS OF MISSOURI'S ACCOMPLISHMENTS! MO-AFP.ORG 23

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Removing the Stigma of Addiction

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morphine drip and then was prescribed opioids for over six months due to a traumatic brain injury that caused migraines I couldn’t function through.

When I was taken off the opioids, withdrawals kicked in and I started trading methamphetamine for people’s prescriptions of morphine. The prescriptions didn’t cause my addiction problem; they just added one more drug to the list of drugs I was already actively misusing. I would love to recount stories of the multiple times I overdosed, but honestly, all I remember is using and then being in a bed in the hospital going through withdrawals.

)

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y first memory is of being molested by a baby sitter at three, which continued for several years. My father had an active alcohol use disorder, and my first week of fifth grade my mother left my father and dropped me and my siblings off at her parent’s house. My grandfather was one of the most evil, abusive people I have ever met. I lived in constant fear; with some of the beatings ending with him calling the school and letting them know I would be helping him on the farm for a week. That week would allow the bruises to heal and then I would go back to school.

I come from a long line of people with a bipolar diagnosis. I too, live with bipolar disorder, and I lived with PTSD for years. The trauma went undiagnosed and untreated for a long time. I did everything I could to cope, numb and escape the trauma. Nothing worked until the summer before my seventh grade year. That summer, I found something that allowed me not only to numb and escape, but to find a group of kids I finally fit in with and felt accepted by.

I tell you all of this so I can also talk about what comes next without you instantly judging me and writing off anything I have to say. The thing I found that finally helped was marijuana, then alcohol.

That progressed on to methamphetamine and eventually opioids. They all served a purpose and I felt they were necessary. By the time negative consequences started occurring, I was physically and psychologically dependent on them. I had an active substance use disorder for almost 25 years.

Over the course of those 25 years, I went to jail multiple times beginning at age 17, and eventually ended up in prison at 20 where I got the GED I eventually turned into a Master’s degree. I have been coded on eight separate occasions: alcohol poisoning at 17, three times after a car accident at 22, a suicide attempt at 23 and three separate opioid overdoses from 28-29.

My opioid use disorder started after my car accident at 22. I came out of a coma with a

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

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I wrote this for the people who feel addiction is a choice and all it takes is willpower to overcome.

That is a false dichotomy.

For many of us, our substance use disorder did start out with a choice. Our use progressed to misuse, and then over time we developed a substance use disorder. That progression from choice to disease is true in many other diseases people develop. Once the choice is made, the progression is then influenced by genetics, environment and pre-existing mental health disorders. Many people can misuse alcohol or other drugs while never developing a substance use disorder the same way many people can eat poorly and live a sedentary lifestyle yet not develop Type 2 diabetes. But there are others, that due to some of the factors we talked about above, will develop a substance use disorder or Type 2 diabetes.

I also wrote this to normalize substance use

"

I have had a probation officer tell me I was beyond repair, and heard emergency room staff call me a frequent flyer and a drug seeker when I was there for legitimate reasons.

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After all, dead people never find recovery.

disorders and share some of the things I have been able to do in my recovery, so that hopefully people with a substance use disorder will be treated with more compassion and empathy than they often are.

I have had a probation officer tell me I was beyond repair, and heard emergency room staff call me a frequent flyer and a drug seeker when I was there for legitimate reasons. My hope is that, through sharing parts of my story people may think twice before writing someone off or treating them poorly. After all, dead people never find recovery.

"

David Stoecker is a person in long-term recovery. For him, that means he has not used alcohol or other drugs since January 31st, 2009 and because of that he has an amazing life today. David is the Advocacy and Education Outreach Coordinator for the Missouri Recovery Network. Prior to that he was a counselor for Preferred Family Healthcare working with the Greene County Treatment Court System for nine years. He was the 2017 Missouri Mental Health Champion for Recovery and sits on several boards, including the Substance Use, Prevention and Recovery State Advisory Council. He is the director of the non-profit organization Better Life in Recovery and co-founder of the Springfield Recovery Community Center.

Stoecker loves hosting pro-social recovery events and spending time with his amazing wife and two incredible children.

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GUIDELINE FOR PRESCRIBING GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN OPIOIDS FOR CHRONIC PAIN IMPROVING PRACTICE THROUGH RECOMMENDATIONS IMPROVING THROUGH RECOMMENDATIONS CDC’s Guideline for PRACTICE Prescribing Opioids for Chronic Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain CDC’s Guideline for Prescribing for Chronic Pain is intended to improve communication between and providers and treatment, and reduce the risks Opioids associated with long-term opioid therapy, including opioid use disorder overdose. patients aboutisthe and benefits of opioid therapy for chronic improve the safety andoreffectiveness of pain The Guideline notrisks intended for patients who are in active cancerpain, treatment, palliative care, end-of-life care. treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose.

The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid Nonpharmacologic therapy and nonopioid pharmacologic therapy therapy only if expected benefits for both pain and function are are preferredtofor chronic risks pain.toClinicians should consider anticipated outweigh the patient.

If opioids areopioid used, therapy onlybe if expected for both pain andtherapy function are they should combinedbenefits with nonpharmacologic and anticipatedpharmacologic to outweigh risks to theaspatient.

If opioids are used, nonopioid therapy, appropriate. they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

Before starting opioid therapy for chronic pain, clinicians

1 1 2 2

should establish treatment goals with all patients, including Before starting opioid for chronic pain, clinicians realistic goals for paintherapy and function, and should consider how shouldtherapy establish goals with all patients, opioid willtreatment be discontinued if benefits do notincluding outweigh realistic goals forshould pain and function, andtherapy shouldonly consider how risks.

Clinicians continue opioid if there is opioid therapy will be improvement discontinued in if benefits not outweigh clinically meaningful pain anddofunction that risks. Clinicians should continue outweighs risks to patient safety. opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risksand to patient safety.during opioid therapy, clinicians Before starting periodically

3 3

CLINICAL REMINDERS

are not first-line or routine CLINICAL • OpioidsREMINDERS therapy for chronic pain • Opioids are not first-line or routine and measure therapy for chronic paingoals for pain • Establish and function • Establish and measure goals for pain benefits and risks and and function • Discuss availability of nonopioid therapies with Discuss benefits and risks and • patient availability of nonopioid therapies with patient

should discuss with patients known risks and realistic benefits Before starting opioid therapy, clinicians of opioid therapyand andperiodically patient andduring clinician responsibilities for should discuss with patients known risks and realistic benefits managing therapy. of opioid therapy and patient and clinician responsibilities for managing therapy.

LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html 26

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html

Missouri's State Targeted Response (STR) to the opioid crisis grant outcomes Below are some quick statistics of what Missouri has accomplished so far. Many thanks to the leaders at Department of Mental Health, Missouri Institute for Mental Health and multiple partners around the state who are dedicated to reducing harm and saving lives.

1,783 individuals have received evidence-based medical treatment for opioid use disorder (OUD).

4,318 Naloxone kits have been distributed to at-risk individuals and their loved ones, and clinicians who work with at-risk populations.

4,061 individuals have received training on what to do in the event of an opioid overdose.

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3,066 bed nights of recovery housing have been provided.

Over 1,100 individuals have received recovery services at the four Recovery Community Centers (RCCs) across the state.

Over 1,000 individuals have received peer-based post-overdose outreach in emergency rooms through the Engaging Patients in Care Coordination (EPICC) Project.

4,633 youth have been engaged through the Generation Rx program, which increases public awareness about prescription medication misuse.

Over 10,000 individuals have received training at 62 agencies through 85

trainings and consultations on topics across the spectrum of treatment, prevention and recovery. Trainings took place at a variety of settings including DMH facilities, state-funded agencies, hospitals, schools and universities, pharmacies, recovery houses, conferences, and more.

29 total Chronic Pain Management and Opioid Use Disorder ECHO sessions were held, reaching 208 unique participants.

98 individuals received training to obtain their Certified Peer Specialist (CPS) credential.

ONE Patient's Perspective...

Mr. William Meier of Ballwin, Missouri, recently shared with MAFP that, after a fracture, he developed pain that persists after years of nonpharmacologic and pharmacologic interventions, including nonopioid and opioid medications. He, like many patients prescribed opioid medications for a documented condition by a physician with whom they have a continuity relationship, expresses concern that he will be “forgotten” or that members of Congress may not recognize opioids as a legitimate therapy for some people. “There is an epidemic of opioids that

must be addressed,” Mr. Meier writes, “I get that. But what about those of us with real pain who need these opioids?” He hopes to see Missouri legislators “state publicly that the people who have chronic pain that can’t be treated with other methods will still have the opioids they need to control their pain.”

Addressing this Crisis Together

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n response to the federal government's declaration that the U.S. opioid epidemic is a national public health emergency, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded a twoyear grant to the American Academy of Addiction Psychiatry (AAAP) to bring together a coalition of 22 health care organizations, including the AAFP, to address the problem at the state and territory level.

As a member of the consortium, the AAFP is recruiting family physicians who have expertise and/or experience in OUDs and use of medications in treating them or who are interested in obtaining a waiver to prescribe MAT to participate in the STR-TA program.

Physicians selected to serve on the technical assistance teams are expected to have a minimum of two years' experience treating patients with OUDs and prescribing medications. These physician team members will be given the opportunity to train/ mentor other physicians in their state or territory in evidence-based practices and will be paid a contractual hourly rate for services after they have been approved as technical assistance consultants.

Known as the State Targeted Response Technical Assistance (STR-TA) Consortium, the coalition seeks to leverage the expertise of individual clinicians in forming technical assistance teams (prevention, treatment and recovery) in each U.S. state and territory. The teams are intended to build clinical proficiency among prescribers and others that will enable them to address chronic pain, opioid use disorders (OUDs) and delivery of medication-assisted treatment (MAT).

Interested in Getting Involved?

"Participation in the STR-TA program will allow us to develop broader teams for comprehensive and compassionate care as we address this public health crisis together."

Family physicians interested in getting involved in their state's or territory's STR-TA team can start by completing a questionnaire (https://www. surveymonkey.com/r/YWPRWGW) about their experience, expertise and interests.

If family physicians would like to learn more about OUDs and training to become better educated on how to prevent, identify and treat these conditions, they can submit a request for assistance (www.getstr-ta. org) from the STR-TA teams.

Julie Wood, MD, AAFP senior vice president of health of the public and interprofessional activities, told AAFP News that the Academy is pleased to partner with the AAAP as a part of the STR-TA Consortium. "Family physicians are on the frontline of care and, given their ability to care for the individual and the entire family, can make a significant impact for those struggling with OUD," she said.

"Participation in the STR-TA program will allow us to develop broader teams for comprehensive and compassionate care as we address this public health crisis together."

Read the full article by Chris Crawford, AAFP, here: www.aafp.org/ news/health-of-the-public/20180619str-tateams.html

— Julie Wood, MD

THANK YOU Missouri Recovery Network

for your contributions to this issue.

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s someone who cares about the mother and her baby, you have an opportunity to offer help and support to start her on the road to recovery and to deliver a healthy child. The mother-to-be may face harsh judgment from others, including the medical community, but don't let this dissuade her from seeking treatment and support. “There is huge stigma for pregnant women who are addicted to opioids,” explains Adam Bisaga, MD, Research Scientist, New York State Psychiatric Institute and Professor of Psychiatry, Columbia University Medical Center.

There’s already stigma with addiction. There’s already stigma with addiction in women. There’s even more stigma with addiction in pregnant women. This can deter a woman from getting good treatment and seeking help.

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Pregnancy and Opioids

Keep in mind that the mother herself may be feeling ambivalent about the pregnancy. One study indicates that 86 percent of pregnancies in women with an opioid use disorder are unplanned.

What You Can Do • Offer compassion, and reassurance and listen without judgment.

• Be mindful of the words you use. For example, words like “junkie” and “addict” can be hurtful.

Instead, you can say “person with an opioid use disorder.”

Get Her to Treatment The mother-to-be will also need treatment to address her physical, psychological, emotional and social issues in addition to her opioid use.

Nineteen states have funded treatment programs for pregnant women. The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a treatment finder, where you can search for pregnancy and post-partum programs across the country. The mother-to-be may also need mental health treatment as an estimated 50 to 80 percent of pregnant women with an opioid 30

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

use disorder also have another mental health disorder. In many if not most cases, traumainformed care is needed as well. This is a treatment framework that involves understanding, recognizing and responding to the effects of all types of trauma. Trauma informed care emphasizes physical, psychological and emotional safety and helps survivors rebuild a sense of control and empowerment. Keep in mind that pregnant women who misuse opioids are at increased risk for pregnancy-associated complications and death.

Untreated substance use disorders have been linked to high risk behaviors, such as prostitution and crime, which can expose pregnant women to sexually transmitted diseases, violence, legal problems and incarceration. It’s essential that the mother-to-be gets proper treatment for her opioid use disorder and gets good medical care for herself and her baby.

Medication-Assisted Treatment is Recommended The use of medication-assisted treatment (MAT) during pregnancy is the recommended best practice for the care of pregnant women with opioid use disorders. MAT is the use of medications in combination with social support and counseling to treat her substance use disorder. Counseling helps people avoid and cope with situations that might lead to relapse. Most doctors treat opioid disorders in pregnant women with either methadone or buprenorphine (often prescribed as buprenorphine/naloxone). These medications prevent withdrawal, reduce cravings and reduce the euphoria associated with illicit use. MAT has been shown to improve outcomes related to maternal adherence to prenatal care, improve nutrition and better infant birth weights as well as reduce exposure to infections from IV drug use such as HIV and Hepatitis C. Under medical supervision, methadone or buprenorphine can reduce the risk of pregnancy complications. These medications are safe for the baby and also allow the mother-to-be to focus on prenatal care and her opioid use disorder treatment and recovery program. Treatment involves taking medications in prescribed doses during pregnancy and after the baby is born. Methadone is only available in specialized clinics. Buprenorphine may be available from a primary care physician or obstetrician if they have received special training. Decisions about

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86%

One study indicates that of pregnancies in women with an opioid use disorder are unplanned.

the right course of treatment are best made by each woman with the help of doctors and providers who specialize in treating pregnant women. For example, her doctor may need to increase her dose of medicine in the third trimester of pregnancy and then can go back to the lower dose after pregnancy.

said Maria Mascola, MD, in an American College of Obstetricians and Gynecologists news release.

"Women with opioid use disorder are dealing with all those things in addition to the challenges of their addiction, which — without treatment and support — can often lead to relapse.”

Note: There are currently no adequate or controlled studies on whether naltrexone (brand name Vivitrol®) is safe during pregnancy. Studies suggest that if a woman is already stable on Vivitrol®, she should continue treatment so as not to destabilize recovery.

There is a Risk of Relapse and Overdose: Get LifeSaving Medicine Naloxone One of the biggest risks of opioid use disorder is overdose. If the mother-to-be/new mother relapses and takes too much of an opioid, her breathing may slow down or stop and she could die. Naloxone (brand name Narcan) is a drug that stops the effects of opioids when used in time. It’s important to have Naloxone on hand as a precautionary measure in case she relapses — it can save her life if she overdoses.

What You Can Do • Call your state health and human services department specializing in substance use to find a facility that offers treatment for pregnant women with methadone or check out the Suboxone Treatment Provider Locator.

• Encourage the mother-to-be to begin treatment with medications.

• Participate in family therapy, if available.

Note: Medically supervised detox may be considered in women who do not accept MAT or when treatment is unavailable. In that case, a doctor experienced in treating prenatal addiction should supervise care, with informed consent of the woman.

The Weeks and Months After Delivery “The patient will need support for how to be a mother and how to take care of her child,” says Dr. Bisaga. “This is needed for when she’s doing well and for when she’s not doing well.” The weeks and months after the baby is born can be a stressful time for women in recovery. The new mother should be sure to continue treatment for her substance use disorder, attend parenting support programs and counseling/relapse prevention programs. The new mother should not make a decision to stop her methadone or buprenorphine too quickly or too soon because this increases the risk of relapse. It is important for her to discuss decisions about her medication with her doctors.

"The postpartum period is already a vulnerable time for new moms, in general, as they face the stresses of sleep deprivation, caring for a newborn and possibly symptoms of postpartum depression,"

What You Can Do • Make sure you have naloxone on hand and know how to use it.

• Ask her provider to write a prescription for naloxone or a referral to a public health program which dispenses it.

With your support, encouragement and reassurance, along with good medical care, the mother-to-be can have a healthy pregnancy and deliver a healthy baby. And the baby, with developmental support, good pediatric well-child care and a healthy, nurturing and caring environment will grow into a healthy child.

This guide was informed by discussions with: Dr. Adam Bisaga, M.D.; Steven H. Chapman, M.D.; Julia R. Frew, M. D.; Hendrée Jones, PhD Additional sources: American College of Obstetricians and Gynecologists (ACOG); American Society of Addiction Medicine ASAM; National Institutes of Health (NIH); Providers’ Clinical Support System For Opioid Therapies (PCSS-O); Substance Abuse and Mental Health Services Administration (SAMHSA) Visit drugfree.org for more information and to download the full guide.

MO-AFP.ORG 31

AAFP, Others Drive Home Opioid Message on Capitol Hill

E Michael Munger, MD AAFP President

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very day in the United States, more than 1,000 people are treated in emergency departments after misusing prescription opioids. And every day, roughly 100 Americans die from opioid overdoses.

The opioid epidemic has long been front and center for the AAFP and continues to be one of the major public health challenges facing us.

Here I am on Capitol Hill -- that's me on the far left -- along with colleagues from the American Academy of Pediatrics (not shown here), American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association.

Today, the House voted on legislation intended to serve as a vehicle for a massive package aimed at addressing the opioid crisis. Representatives have spent the past few weeks passing dozens of bills related to the issue, and HR 6, the SUPPORT for Patients and Communities Act, is an umbrella bill that brings them all together.

The measure passed handily on a 396-14 vote.

The AAFP has and will continue to engage Congress and HHS to advocate solutions to the nation's opioid epidemic on behalf of our members and patients. Last week, the AAFP, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association released joint principles regarding the opioid epidemic that are intended to inform congressional policymakers.

On June 18, I, along with the other presidents from our coalition, followed up with a day of meetings with members of Congress, congressional staff and representatives from HHS in Washington.

In those meetings, we emphasized seven key points from our joint principles. Our organizations, which together represent more than 560,000 physicians and medical students, have recommended the following: • Align and improve financial incentives to ensure access to evidence-based opioid use disorder treatment by ensuring coverage and funding for Medicaid, medication-assistant treatment and parity enforcement.

• Reduce administrative burdens associated with treatment.

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

• Incentivize more physicians to treat substance use disorders (SUD). Create a pipeline of addiction professionals to create a robust behavioral health workforce.

Expand effective models of care to alleviate workforce shortages and broaden the use of telehealth.

• Focus on public health approaches to SUD by addressing childhood stress, ensuring services for pregnant women, access to naloxone, and fair and appropriate treatment for individuals in the criminal justice system.

• Increase access to evidence-based treatment for pregnant women and other mothers to improve maternal and child outcomes.

• Ensure that efforts to reduce opioid misuse do not interfere with the physician-patient relationship and doctors' ability to help manage pain. Support research focused on evidence-based, nonpharmacological alternatives for pain management.

• Reduce stigma related to SUD. HR 6 will not be the ultimate answer to this multifactorial problem we are facing. The AAFP recently wrote to House leadership to acknowledge the bipartisan efforts that have led to this important first step. However, much work still lies ahead, and it's unclear when the Senate will act to address the issue.

The Academy is urging legislators to include support for NIH opioid research and improved prescription drug monitoring programs in any final opioid legislation. You can make your voice heard by utilizing the AAFP's Speak Out tool.

The AAFP will continue to advocate on behalf of our members and their patients to find solutions to this public health crisis.

EMERGENCE OF A CRISIS Where it all began...

1861-1865 - During the Civil War, medics use the drug morphine as a battlefield anesthetic. Many soldiers become dependent on morphine following the war.

1898 - Heroin is first produced commercially by the Bayer Company. At this time, heroin is believed to be less habit-forming than morphine, so it is dispensed to individuals who are addicted to morphine, thus exacerbating their addiction.

july 31, 2017 - After a delay, the White House panel examining the nation's opioid epidemic releases its interim report, asking President Trump to declare a national public health emergency to combat the ongoing crisis.

1924 - The Anti-Heroin Act bans the production and sale of heroin in the U.S.

November 1, 2017 - The opioid commission releases a final report. Fifty-six recommendations which include a proposal to establish nationwide drug courts which would place opioid addicts in treatment facilities rather than prison.

1914 - Congress passes the Harrison Narcotics Act, which requires written prescriptions for narcotic drugs. Importers, distributors, and manufacturers of narcotics must register with the Treasury Department and pay taxes.

1970 - The Controlled Substances Act becomes law. It creates groupings of drugs based on the potential for abuse. Heroin is a Schedule I drug while other opiates such as fentanyl and methadone are Schedule II. January 10, 1980 - A letter titled "Addiction Rare in Patients Treated with Narcotics" is published in the New England Journal of Medicine. It was not a study, yet looked at incidences of addiction in a very specific population of hospitalized patients. This article would become widely cited as proof that narcotics were a safe treatment for chronic pain.

1995 - OxyContin, a long acting version of oxycodone, is introduced and marketed as a safe pain pill by manufacturer, Purdue Pharma.

May 10, 2007 - The federal government brings criminal charges against Purdue Pharma for advertising OxyContin as less addictive and safer than other opioids.

The company is charged with "misleading and defrauding physicians and consumers." Purdue Pharma pleads guilty, agreeing to pay a $634.5 million in criminal and civil fines.

2010 - FDA approves an "abuse-deterrent" formulation of OxyContin, to help curb abuse. Yet, people are still finding ways to abuse it.

May 20, 2015 - The DEA announces that it has arrested 280 people, including 22 doctors and pharmacists, after a 15-month sting operation centered on health care providers who dispense large amounts of opioids. The sting, nicknamed Operation Pilluted, is the largest prescription drug bust in the history of the DEA.

March 18, 2016 - The CDC publishes guidelines for prescribing opioids for patients with chronic pain. Recommendations include prescribing over-the-counter pain relievers like acetaminophen and ibuprofen in lieu of opioids. Doctors are encouraged to promote exercise and behavioral treatments to help patients deal with the pain.

March 29, 2017 - President Trump signs an executive order calling for the establishment of the President's Commission on Combating Drug Addiction and the Opioid Crisis. New Jersey Governor Chris Christie is selected as the chairman of the group.

September 22, 2017 - The pharmacy, CVS, implements new restrictions on filling prescriptions for opioids, dispensing only a seven-day supply to patients who are new to pain therapy.

February 9, 2018 - A budget agreement signed by President Trump authorizes $6 billion for opioid programs, with $3 billion allocated for 2018 and $3 billion for 2019.

February 27, 2018 - Attorney General, Jeff Sessions announces a new opioid initiative: the Prescription Interdiction & Litigation (PIL) Task Force. Its mission is to support local jurisdictions that have filed lawsuits against prescription drugmakers and distributors.

March 19, 2018 - The Trump administration outlines an initiative to stop opioid abuse. Concentrating on law enforcement and interdiction; prevention and education by way of an ad campaign; and job-seeking assistance for individuals fighting addiction.

April 9, 2018 - The U.S. surgeon general issues an advisory recommending that Americans carry the opioid overdose-reversing drug, naloxone. A surgeon general advisory is a rarely used tool to convey an urgent message. The last advisory issued by the surgeon general, had to do with drinking during pregnancy.

May 1, 2018 - The Journal of the American Medical Association publishes a study that finds synthetic opioids like fentanyl caused about 46% of opioid deaths in 2016. That's a three-fold increase compared with 2010, when synthetic opioids were involved in about 14% of opioid overdose deaths. It's the first time that synthetic opioids surpassed prescription opioids and heroin as the primary cause of overdose fatalities.

June 7, 2018 - The White House announces a new multimillion dollar advertising campaign to combat opioid addiction.

References: Data Overview. Drug Overdose. CDC Injury Center, Centers for Disease Control and Prevention 2016; Excerpted from 2018 Cable News Network Library 10/29/17; Wikipedia: Opioid epidemic: https://en.wikipedia.org/wiki/ Opioid_epidemic

MO-AFP.ORG 33

A Modest Proposal Aimed at Reducing Neonatal Abstinence Syndrome

T Mat Reidhead, MA, Vice President of Research and Analytics, Missouri Hospital Association, Hospital Industry Data Institute

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he Missouri Hospital Association released a policy brief in June with two overarching aims. First, we sought to quantify the incidence of Neonatal Abstinence Syndrome in Missouri using both conventional and novel surveillance techniques to better understand the potential of undercoding these births. Second, we proposed and evaluated the cost effectiveness of expanding Medicaid to low-income, uninsured women of childbearing age for substance use disorder and mental health treatment to reduce the number of infants born with opioid withdrawal in Missouri.

Neonatal Abstinence Syndrome is the clinical term for infants born with severe opioid withdrawal as a result of maternal use during pregnancy. Infants with NAS experience higher neonatal intensive care unit admission rates and an average hospital stay of 17 days at birth. In addition, depending on the severity of the mother’s opioid use, 60 to 80 percent of newborns with NAS require pharmacological treatment to physically support the infant through the withdrawal until opioids are out of the system.i

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

The Medicaid program pays for more than eight out of every ten newborns with NAS in Missouri.

It is estimated that the additional hospital costs associated with NAS for labor, delivery and neonatal care amounted to $10 million in additional spending

by Missouri’s Medicaid program in 2016 alone.

A review of national data sources on the opioid epidemic suggests that the NAS crisis is rapidly outpacing other measures of the adverse consequences of the larger opioid crisis in the U.S: • Between 2005 and 2014, the opioid-related overdose mortality rate in the U.S. increased from 4.5 to 8.8 per 100,000—a ten year increase of 95.6 percent.

• During the same period, the rate of opioidrelated hospital emergency department utilization in the U.S. increased from 89.1 to 177.7 per 100,000—a 10 year increase of 99.4 percent.

• Between 2004 and 2013, the rate of NAS increased from 7 to 27 per 1,000 admissions to a NICU in the U.S.—a 10 year increase of 286 percent.

Using conventional surveillance of hospital diagnosis codes we found that the incidence of NAS in Missouri increased 270% between 2008 and 2017 (figure 1). However, linking new and expectant mothers to hospital utilization for opioid misuse, and survey-based methods suggest the rate of NAS may be understated by as much as 400% (table 1).

We also estimated that the cost of a federal Medicaid waiver to provide access to substance

60-80%

"

"

Depending on the severity of the mother’s opioid use, of newborns with NAS require pharmacological treatment to physically support the infant through the withdrawal until opioids are out of the system.

use treatment for low-income women before they become pregnant would be offset by the avoided Medicaid costs to care for the NAS-affected babies these women would likely give birth to without the treatment. Avoided NAS births will also result in avoided foster care placements and other downstream costs associated with NAS. The policy brief estimates the 10-year cost to the state general revenue fund to provide upstream substance use treatment is $14.5 million less than the costs of NAS-related care and social services that would otherwise be expected.

Taking steps to ensure potential, expectant and new mothers have the resources needed to overcome substance use disorder is a critical step to reducing health care and societal costs associated with NAS. Providing low-income, uninsured women with substance use recovery resources before pregnancy occurs, or as early in the pregnancy as possible, would prevent NAS from occurring — dramatically improving outcomes for these children and potentially saving the system millions in downstream medical, social services, foster care, law enforcement and educational spending.

References: McQueen, K., Murphy-Oikonen, J. (2016). Neonatal Abstinence Syndrome. New England Journal of Medicine. 375(25): 2468-2479. Available at https://www.nejm.org/doi/pdf/10.1056/NEJMra1600879; Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2016 on CDC WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Retrieved from http://wonder.cdc.gov/ mcd-icd10.html; Weiss, A.J., Elixhauser, A., Barrett, M.L., Steiner, C.A., Bailey, M.K., O’Malley, L. (2016). Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014. HCUP Statistical Brief #219. Agency for Healthcare Research and Quality, Rockville, MD. Available at https://www.hcup-us.ahrq.gov/reports/statbriefs/ sb219-Opioid-Hospital-Stays-ED-Visits-by-State.pdf ; Tolia, V.N., Patrick, S.W., et al. (2015). Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs. New England Journal of Medicine. 372(22): 2118-2126. Available at https://www.nejm.org/doi/pdf/10.1056/NEJMsa1500439

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MO-AFP.ORG 35

Leaders Convene in Kansas City

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SAVE THE DATE April 24-27, 2019 Kansas City, MO

Interested in representing Missouri constituencies at ACLF/NCCL? All members are welcome to attend the conference, regardless of whether you meet the requirements of a particular constituency.

he American Academy of Family Physicians held their annual leadership conference April 26-28, 2018, in Kansas City. Missouri was well represented at both the Annual Chapter Leadership Forum (ACLF) and the National Conference of Constituency Leaders (NCCL) during this three-day meeting. MAFP President, Sarah Cole, DO, FAAFP, and Past President, Kathleen Eubanks-Meng, DO, and the MAFP staff attended sessions on high performing boards, effective governance practices, board-staff roles and responsibilities, communication skills, member engagement, and other important leadership topics.

Missouri had a full slate of delegates at the National Conference of Constituency Leaders held concurrently with ACLF. NCCL is the AAFP’s premier policy development event for underrepresented constituencies and our delegates are listed below: • • • • •

Women – Amelia Frank, MD (Columbia) Minority – Afsheen Patel, MD (Kansas City) New Physician – Kara Mayes, MD, MD (St. Louis) IMG – Arihant Jain, MD (Cameron) LGBTQ – Tess Garcia, MD (Kansas City)

In addition to participating in leadership sessions, NCCL delegates write, debate, and vote on resolutions related to medical practice and patient health.

During the lunch program on April 27, the MAFP was recognized for sending a full delegation to the 2018 NCCL. Derrick Kayongo, a Ugandan refugee, provided the luncheon keynote address on how he became a successful entrepreneur and human rights activist.

Mr. Kayongo is the founder of the Global Soap Project, which recycles used hotel soap and redistributes it to impoverished countries. In creating this global humanitarian initiative, he demonstrated that a simple, yet novel idea has the power to transform lives.

L-R: Afsheen Patel, MD; Sarah Cole, DO, John Heafner, MD; Kara Mayes, MD; Amelia Frank, MD; Arihant Jain, MD

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

“It was a unique conference of shared learning and was an opportunity to meet and talk with AAFP leadership. The conference attendees heard keynote speakers and learned about how AAFP is working to ease family physicians’ regulatory and administrative burdens. As a first-time attendee, it provided me insight of the AAFP policy making process and how to get involved in AAFP leadership. Most importantly, this gathering provided an open climate of communication with our peers and an opportunity to forge new relationships, exchange ideas, and create solutions to current problems faced by family physicians all over the country.” Arihant Jain, MD “Attending the NCCL for the second time reinforced my love of this conference and of our Academy. I was happy to be Missouri’s representative for the New Physician constituency. The speakers, AAFP Board Members, and NCCL leadership were inspiring for all of the emerging leaders who attended the conference.

Resolutions that passed included supporting family physicians that are interested in state or local politics, addressing physician/resident/student burnout, increasing access to school-based mental health programs, and much more. More than anything, the networking and friendships made at NCCL continue to be a large benefit to me. I encourage anyone, particularly physicians in their first few years of practice, to attend NCCL in the future. It is a great source of inspiration and a pathway to leadership opportunities.” Kara Mayes, MD “AAFP’S NCCL conference is a place to create lifelong friendships, to get things done, and to make a difference. This was my second year at NCCL and I was again inspired by the commitment and passion that the delegates at the conference have for family medicine, for our patients, and for our world. I arrive excited to get to work creating change for AAFP and I leave feeling energized at having met so many, wonderful, like-minded people who just want to help and make things better. It is wonderful to be a room with so many voices that don’t usually have place at the table and to see what awesome things they can accomplish.

I am so glad and proud to be a part of NCCL and to be Missouri’s Women’s delegate!” Amelia Frank, MD

Missouri Docs Take on Capitol Hill

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his year’s Family Medicine Advocacy Summit (FMAS) in May attracted more than 225 Family Physicians from across the country.

Missouri’s delegation included MAFP Advocacy Commission Co-Chair, Peter Koopman, MD, FAAFP, District 1 Board Member, John Burroughs, MD, AAFP Key Contact, Kurt Bravata, MD, and MAFP Executive Director, Kathy Pabst, MBA, CAE. Attendees learned from experts how to work with legislators to improve their practices and their patients' lives.

The FMAS is an opportunity to better understand federal advocacy from current members of Congress and their staff, learn about the current priorities for family medicine from AAFP governmental affairs, get advice from policy experts and professional lobbyists, as well as receive practical, hands-on experience with the legislative process.

In addition, the delegates met with the Missouri senators and representatives to discuss measures that could fix the nation's health care system. Missouri delegates expressed their perspective on the alternative payment model for advanced primary care, chronic pain management, insurance market stabilization, and the Congressional Primary Care Caucus (To date, Congressman Blaine Luetkemeyer is the only Missouri representative to sign on – thank you Congressman Luetkemeyer.) But most of all, they were the voice of their patients and shared their stories to our elected leaders.

This was Dr. Bravata’s first time advocating for Missouri patients and family physicians.“The FMAS was a fantastic event, not only because of the chance to advocate on behalf of the greater family medicine community, but also because of the incredible networking opportunities and the benefit of attending presentations by Senator Cory Gardner (R-CO), Michael G. Gottleib, JD (Ballast Research), Jene Grandmont, MSW (Health Landscape), Amy Hall (U.S. House of Representatives Minority Staff

Senate Issues

Director), Kimberly Leonard (Senior Healthcare Writer for the Washington Examiner), Rep. Brad Schneider (D-IL), and others from the AAFP Board of Directors.”

Peter Koopman, MD, FAAFP, facilitated the discussions with our legislators as we attended as many appointments as possible as a Missouri contingency.

“The FMAS remains the most important advocacy work I am able to do all year. In two days, I am able to hear about

AAFP priorities and advocacy work, improve my advocacy skills and meet with multiple congressmen/women and senators. Over the years, I have developed relationships with my senators and their staffs and strongly believe the relationships and work done here benefit the specialty of family medicine and our patients. The wheels of our government turn slowly if at all, and sometimes the lack of progress and change frustrates me, but over more than five years, I can see an increasing degree of respect and acknowledgement for the work that family medicine does for our patients and health care system. This is essential work!”

Peter Koopman, MD, FAAFP, MAFP Advocacy Commission Co-Chair

L-R: Peter Koopman, MD, FAAFP; Kurt Bravata, MD; John Burroughs, MD

FAMILY MEDICINE ADVOCACY SUMMIT

ACE Research Act (Part of S. 2406) AAFP supports provisions to expand chronic pain research.

Rural Physician Workforce Production Act of 2018 AAFP supports increasing rural GME funding.

Maternal Health Accountability Act (S. 1112) AAFP supports research and data collection to improve our nation’s understanding about the causes of pregnancy-related maternal death with goal to improve maternal and child health.

House of Representatives Issues

Primary Care Patient Protection Act of 2018 (HR 5858) AAFP supports modifications to the Health Savings Account law which includes up to two primary care visits in any high deductible health plan for no cost sharing.

ACE Research Act (HR 5002) - on Opioids AAFP supports bill to expand chronic pain research and increased access to substance abuse treatment through Medicaid and Medicare.

Connections Act (HR 5812) - on Opioids AAFP supports improvements to state prescription drug monitoring programs (PDMPs).

Preventing Maternal Deaths Act (HR 1318) AAFP supports expanding state-based maternal mortality data collection, which will help inform policies to improve maternal and child health.

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Draws Attendees from all Four Corners of the

Show Me State

T

he Show Me Family Medicine Conference (formerly the Annual Scientific Assembly), again exceeded expectations by family physicians practicing in a variety of settings. Over 75 people came together to increase their knowledge about clinical and practice issues, recognize and celebrate MAFP members, and to relax at the Lodge at Old Kinderhook in Camdenton. This conference also attracted residents and students to attend. Morgan Dresvyannikov, a third-year medical student at University of Missouri Kansas City was thankful that she attended, “Some of the lectures even helped me get some questions right on a mid-term I took today!”

Friday evening, the MAFP Awards and Installation Dinner was held, recognizing members and new officers. David Campbell, MD, FAAFP, was recognized as your 2018 Family Physician of the Year, and Sarah Cole, DO, FAAFP, was installed as your new President. Other members were recognized for their years of

2018 Tar Wars Poster Contest 1st place poster.

THANK YOU

TO OUR EXHIBITORS & SPONSORS FOR YOUR CONTINUED SUPPORT OF MAFP! 38

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

membership in the MAFP (page 39). The Family Health Foundation of Missouri Tar Wars Poster Contest winner, Keagan Christopher, 5th Grade, Pickett Elementary School, St. Joseph, won the coveted first place prize of $100 (see Keagan's poster below). Saturday evening held the Family Fun Fiesta for a little relaxation and family time.

“

Some of the lectures even helped me get some questions right on a mid-term I took today!"

- Morgan Dresvyannikov, Student, UMKC

•SHOW ME FAMILY MEDICINE CONFERENCE•

A Celebration of Membership Thank you for your continued support and dedication to Missouri family medicine and your patients.

25 Years of Membership

Lynn Allison, MD, Branson Kelvin Bailey, MD, Tuscumbia Bruce Bellamy, MD, FAAFP, Clinton Christopher Best, MD, FAAFP, Kansas City Michelle Britton-Mehlisch, MD, Lee's Summit John Burroughs, MD, Liberty* Steven Charochak, DO, Blue Springs Caroline Day, MD, MPH, Saint Louis Kendall De Selms, DO, Cameron Kenneth DeCoursey, MD, Jackson Michael Di Bernardo, MD, Kansas City Susan Even, MD, Columbia Cynthia Farrar, MD, Faucett Akinrinola Fatoki, MD, Saint Louis Scott Griswold, MD, Eldon Marcel Haulard, MD, Wright City Leonard Hoffmann, MD, O' Fallon Tawnyia Jerome, MD, Jefferson City Henry Konzelmann, MD, FAAFP, De Soto Richelle Koopman, MD, MS, FAAFP, Columbia Erik Lindbloom, MD, MSPH, FAAFP, Columbia Jennifer Livingston, MD, Leawood David Melchior, DO, FAAFP, Perryville V Messmore Arn, MD, Belton James Miller, DO, FAAFP, Butler Donna Roberts, MD, Springfield Fred Rottnek, MD, FAAFP, Creve Coeur Roger Sacry, MD, Carthage Jennifer Scheer, MD, FAAFP, Gerald Todd Shaffer, MD, MBA, FAAFP, Lee's Summit Sanjay Sharma, DO, Saint Louis Deanna Siemer, MD, Jackson Melanie Smolen, MD, Grandview Lori Snook, DO, FAAFP, Maryville Liza Stanton, MD, FAAFP, Saint Louis James Tarwater, DO, Kansas City Jamie Ulbrich, MD, FAAFP, Marshall* Mary Wardell, MD, Springfield Patricia Williams, MD, Brentwood

30 Years of Membership

Paul Andelin, MD, Aurora William Bednar, MD, FAAFP, Kansas City Rene Bollier, MD, FAAFP, Kansas City Gregory Boyd, DO, Lee's Summit Jessee Crane, MD, Glencoe Roderic Crist, MD, Cape Girardeau Thomas Dahlberg, MD, FAAFP, Blue Eye Druery Dixon, MD, West Plains Melanie Elfrink, MD, Marshall

Jan Finney, DO, Bunceton Glennon Fox, MD, Saint Louis Mary Fox, MD, Saint Louis Robert Hausam, MD, Columbia Nancy Hayes, MD, FAAFP, Mountain Grove Joe Himes, MD, FAAFP, Clever Thomas Hopkins, MD, Lamar David Howell, MD, FAAFP, Hazelwood David Kapp, MD, FAAFP, Perryville William Kessler, Jr., MD, FAAFP, Joplin William Kimlinger, MD, FAAFP, Jefferson City Edwin Kraemer, MD, Lee's Summit* Brian Lenz, MD, MBA Wildwood Scott Marrs, DO, Schertz, TX David McCormick, MD, FAAFP, Kansas City James McDowell, MD, FAAFP, Macon David Meece, MD, Jackson Wendy Meyr-Cherry, MD, Saint Charles Ronald Nichol, DO, FAAFP, Kansas City Timothy O'Keefe, MD, FAAFP, Joplin Bernie Parrish, MD, Springfield Hansa Patel, MD, Wilmette, IL Carin Reust, MD, FAAFP, Columbia Joseph Santiago, MD, FAAFP, Saint Louis Mark Schultz, MD, Springfield Jeffrey Scott, MD, Grandview James Shelton, MD, FAAFP, Saint Joseph Lori Smith, MD, Rolla Jeffrey Tedrow, MD, FAAFP, Bolivar James Thompson, MD, FAAFP, West Plains Barton Warren, MD, Richland Jon Wilson, DO, Everton Beth Zimmer, MD, Weldon Spring

James Taylor, MD, FAAFP, Manchester Austin Tinsley, MD, FAAFP, Poplar Bluff* Ted Vargas, MD, Eureka Samuel Watts, MD, FAAFP, El Dorado Springs Edmond Weisbart, MD, FAAFP, Olivette James Weiss, MD, Jefferson City

40 Years of Membership

Gary Bodenhausen, MD, FAAFP, Blue Springs Mahmood Choudhury, MD, FAAFP, Springfield Devera Elcock Skimming, MD, FAAFP, Chesterfield Crisanto Gualberto, MD, FAAFP, Vandalia Carl Myers, MD, FAAFP, Weatherby Lake Kerrin Papreck, MD, FAAFP, Kansas City Chris Sandberg, MD, Saint Joseph Philip Shanahan, MD, Creve Coeur Marla Tobin, MD, FAAFP, Warrensburg Daniel Vinson, MD, Columbia Russell White, MD, FAAFP, Aurora Michael Wurm, MD, Maryville

45 Years of Membership

Fred Caldwell, MD, Poplar Bluff Malcolm Dickerson, MD, FAAFP, Barnett William Soper, MD, FAAFP, Hernando, FL Robert Wheeler, MD, FAAFP, Harrisonville

50 Years of Membership John Murphy, MD, FAAFP, Pleasant Hill Ambrose Walker, MD, Fort Myers, FL

55 Years of Membership BREAKFAST WITH EXHIBITO 35 Years of Membership Donald Binz, MD, FAAFP, Saint Charles Dennis Boeke, DO, FAAFP, Stockton Michael Bross, MD, Saint Louis Kathi Clement, MD, FAAFP, Saint James Henry Domke, MD, New Bloomfield Elizabeth Garrett, MD, MSPH Columbia Lent Johnson, MD, Hannibal Robert Kleinigger, MD, FAAFP, Leslie Guy Kline, MD, FAAFP, Osage Beach Vicki Kofender, MD, Stilwell, KS Steven Langguth, MD, Springfield Christian Madsen, MD, Saint Louis Rodney McFarland, MD, FAAFP, Grove, OK John Memken, MD, FAAFP, Hannibal Donald Schnurpfeil, MD, Wildwood Robert Shaw, MD, FAAFP, Willow Springs Debra Smithson, MD, FAAFP, Lee's Summit

*Recognized and presented their certificates during the MAFP Awards and Installation Dinner, June 8, 2018.

T. W. Garrison, MD, Camdenton William Hamilton, MD, Verona

SPONSORED BY:

60 Years of Membership

Robert McAfee, MD, FAAFP, Springfield

ethos-labs.com MO-AFP.ORG 39

•SHOW ME FAMILY MEDICINE CONFERENCE•

University of Missouri Kansas City FMR Wins Big in the Poster Contest

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his year’s poster contest for residents and students drew over 10 entries from Missouri’s residency programs. Posters were judged on their relevance to family medicine, research study design (if applicable), and the presentation. Judges were selected from conference attendees who reviewed each entry and submitted their scores which were compiled to identify the winners. This year’s winning entries are:

RESEARCH

CASE STUDY

1st Place - $300 The Prevalence and Outcomes of Birth Tourism at TMC-Lakewood Jessica Richter, DO, MPH, and Timothy Myrick, MD, University of Missouri Kansas City FMR

2nd Place - $200 Unilateral Arm Swelling after Orange Theory Session Daniel O’Loughlin, DO, MPH, Christian Verry, MD, Mercy Family Medicine Residency

2nd Place - $200 Retrospective Analysis of Benefits of Ultrasound Use During Uterine Aspiration Jennifer Cabral, MD, Bhavishya Natotam, DO, Gretchen Stokes, MD, Wael Mourad, MD, University of Missouri Kansas City FMR

In addition to the poster contest, residents and students were asked to participate in a poster presentation session as part of the CME agenda at the Show Me Family Medicine Conference. This year’s presenters were: Jessica Richter, DO, MPH; Lisa Trask, DO; Shannon Marsden, MD; and Taylor Reiman, student.

These are excellent opportunities for family medicine residents and students to develop their scholarly activities and presentation skills. Thank you to all who participated.

3rd Place - $100 Making Healthy Lifestyle Changes Using My Habit Book Ashley Hall, DO, Adam Legg, DO, David Voran, DO, University of Missouri Kansas City

AAFP's LeRoy Confers Bustle as Fellow

A

AFP Board Member, Gary LeRoy, MD, FAAFP from Cincinnati, Ohio, attended the MAFP annual meeting and presented a session on, “Do You See What I See - Primary Care Ophthalmology.” Dr. LeRoy conferred the oath of AAFP Fellow on John Bustle, MD, FAAFP, from Adrian, Missouri during the Awards and Installation Ceremony.

LeRoy also participated in the MAFP Advocacy Commission and Board of Director meetings on Sunday where he provided welcome remarks and engaged in dialogue concerning MAFP legislative and regulatory issues, AAFPs strategic priorities and challenges, and the primary care spend legislation.

Dr. Bustle (right) receives his Degree of Fellow from Dr. LeRoy. 40

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

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Dr. Campbell Named 2018 Family Physician of the Year

“M

L-R: Mark Campbell, Veronica & Dave Campbell, Julie Campbell, and Lynn (Campbell) Golec.

Dr. Campbell has learned a lot. Dr. Campbell has taught a lot. Yet, perhaps more importantly, Dr. Campbell has taught people to learn."

- Tami Timmer, Colleague

ark Schabbing, MD, had the distinct honor to announce this year’s recipient of the Family Physician of the Year. David Campbell, MD, FAAFP, St. Louis, has been a member of AAFP for 39 years and the MAFP for 31 years. He has served our profession well in a variety of settings from academics, as a resident director, a medical director, a practicing physician, military service, and is now the president of a local non-profit organization serving the underserved in his community. His service continued through publishing articles and books, and committee and board service at the local and national levels.

Dr. Campbell was nominated by a colleague, Tami Timmer. "Dr. Campbell has learned a lot. Dr. Campbell has taught a lot. Yet, perhaps more importantly, Dr. Campbell has taught people to learn.” His service to the iFM, the Institute for Family Medicine, is to improve the health of the St. Louis community, one patient, one physician, and one organization at a time. This service is provided through school-based programs, a clinic within an apartment building which houses elderly, people with disabilities, and provides private care to individuals at various locations. As another letter of support stated, “He has lived family medicine.” His ability to identify a need, evaluate what resources exist, define the gaps, and then collaboratively create a costeffective way to address it in partnership reflects Dr. Campbell’s “can do” perspective." (Read Dr. Campbell's acceptance speech on the following page).

MO-AFP.ORG 41

•SHOW ME FAMILY MEDICINE CONFERENCE•

Campbell Acceptance Speech: Thank you to all of my colleagues in the Missouri Academy for honoring me with this award. It seems this a time that lends itself to some reflection on what has, “so far” been a very blessed career.

I want to reflect primarily on the professional aspect, but I will start and end with personal.

My parents were of modest means, neither one with college education, except for some night classes.

My dad was a machinist and worked well past age 70, but what set him apart in a crowd was his compassion and kindness. He was constantly scanning his surroundings to see if there was someone who needed help. Whether it was something as simple as holding the door for a total stranger or dropping whatever he was doing to run someone to the nearest gas station if they had run out of gas – which seemed to happen often on our corner, being the exit ramp off of Interstate 55. Or going every single Saturday afternoon to set up the coffee maker for the social hour between church services the next day. He was always there for me, and he was always there for whomever needed help.

My parents’ sacrifices allowed me to go to Washington University for undergrad and St. Louis University for medical school. My mom lived to be 86 and dad lived to be 90, supporting me in every way, and nurturing a spirit of compassion and kindness.

I was on the educational fast track, which I don’t necessarily recommend, but I graduated from medical school before my 24th birthday. Some people may be mature enough at that age to enter residency – but I am not sure that I was. I survived, and my patients survived, and by my third year of residency I thrived and was selected as chief resident. My program director in the early years of my residency had a huge impact and was a guiding hand in the first decade of my career. Emmitt Lee Taylor was a country doc from Alabama who had joined the Navy later in his career and had just taken over as the residency program director at the Naval Aerospace and Regional Medical Center in Pensacola Florida. On the first day of orientation, Lee gathered the incoming interns and since he had just assumed the role, he announced “I want you to know I didn’t pick any of you.” An intimidating way to start your internship, but that was Lee. From that point on, Lee had a huge impact on my career. After my residency, Lee had taken an assignment in DC at what the Navy called HSETC, health science education and training command. He was able to arrange for me to have the first ever Navy fellowship in family practice faculty development. A few years later, after Lee had gotten out of the Navy to accept the chairmanship at the University of Alabama at Birmingham, he invited me to follow him and be the residency program director of that program, which I did for three and a half years. I then had the opportunity to “come home” to St. Louis and start a new residency from scratch at a community-based hospital, Deaconess Hospital.

That was in 1987, and that is where I encountered the next mentor and guiding hand of my career, the Reverend Richard Ellerbrake. He was the CEO of Deaconess, and I had lunch with him as part of the interview. I had not ever thought that moving back to St. Louis was going to be an option since it was clearly not a hot bed for academic family medicine, or one might say, for family medicine at all. But I met Dick Ellerbrake, and I felt that Deaconess was a place you could grow something special. Dick retired about four 42

MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

years later, much to my disappointment – but we stayed in touch and in 2000 when the hospital had been sold to a for-profit, and the environment for medical education of any kind was deteriorating, Dick agreed to become part of the board of directors for the new not-for-profit that I formed – the Institute for Family Medicine. He is still on my board, and for the last several years has served as the chair of the board.

Dr. Campbell shakes hands with Mark Schabbing, MD.

Before we leave the Deaconess days, there was a side bar story during those years. One of my professors in medical school, a sociologist named Rodney Coe had been appointed as the chair of the Department of Community Medicine at SLU. Rod came to me and asked me to assist him in changing the Department of Community Medicine into the Department of Community and Family Medicine. Since he was a sociologist and not a physician, I represented the family physician in the new department, and at his request, I served as his associate chair while maintaining my role at Deaconess. We lost Rod a few years ago, but he also had served on my board of directors since the formation of the Institute in 2000 and until his death, He also was an important guiding hand in my career.

When I left Deaconess to form the Institute for Family Medicine, one of the motivating factors was an opportunity presented to me by Dr. Paula Livingston. Dr. Livingston is a dentist and is now in practice at Truman Medical Center in Kansas City, I believe. At the time, Dr. Livingston was the Director of the St. Louis County Department of Health. St. Louis County DOH runs primary care clinics for the uninsured and underserved residents of St. Louis county. Dr. Livingston had a vision and a desire to move those clinics to what she called “a family practice model”. She said she had been looking for someone to lead that effort for more than a year and then found me as a result of an inquiry one of my residents had made about referrals. For those who were in St. Louis, or aware of what followed, it was nothing short of brutal. The pediatricians at a local and statewide level went to war trying to stop “family medicine” from taking over the county clinics. Some people jokingly say they get up in the morning and check for their name in the obituaries – well I would check for my name on the front page to see what new hysteria they were stirring up. The chief of pediatrics at Children’s even testified before the county council that “there will

•SHOW ME FAMILY MEDICINE CONFERENCE•

THE FAMILY PHYSICIAN OF THE YEAR AWARD IS BEING RENAMED “Exemplary Achievement in Missouri Family Medicine Award." This will become effective with the 2019 cycle. The eligibility criteria are under review by the Member Services Commission. This change will allow for additional awards to be presented, if warranted. Look for more information and details later this year.

Dr. Campbell acknowleges his family during his acceptance speech.

be dead children in the streets if family practice takes over.”

Of course, my plan was always to engage pediatrics, but no one asked, no one listened. It was my first taste of politics – but Dr. Livingston stood by me and stood by family medicine and said that we had a majority on the county council, so don’t fight back, and we will prevail. We did. And we had a great ten-year run of providing quality primary care in those clinics with primarily family physicians.

So, my speaking time is just about up and I haven’t yet told you about the work of the Institute for Family Medicine, which we now call IFM Community Medicine. When we were awarded the contract from St. Louis County in 2000, we had a brand-new start up not-for-profit with a $2.2 million dollar contract, and the question I asked was “what else can we do”.

The Deaconess residency had been particularly strong in community outreach, blending service and education at places like Crisis Nursery, Every Child’s Hope, Job Corp and Covenant House of Missouri. Many of those organizations were no longer getting the same type of service from Forest Park Hospital and they came to the Institute for help. We reached out to one school district, Jennings, to see if they had an interest in elevating their school health program. Once we began to work with Jennings, more school districts came to us, some with common problems and some with unique issues. So that is what IFM does – we partner with schools, shelters and social service organizations to find creative and cost-effective ways to bring health services to their students, residents, or clients within their walls. I have a dedicated team of nurse practitioners and a small, but very effective staff led by Tami Timmer. We have 18 different locations throughout the St. Louis area where we provide care, sometimes just a half day a week, other times as the medical home. I am privileged to serve as the medical director for 12 school districts including St. Louis Public

and the Special School District. Along with the name change, we adopted a mission statement that says it all in its simplicity – We strengthen underserved communities, one patient at a time.

I said that I would start and finish with my personal heroes and my personal support system. My wife of nearly 44 years, my high school sweet heart – don’t worry that is the same person – Veronica, who has been there supporting me, and a huge behind the scene “volunteer” for IFM. What we have chosen to do for the last 17 years is a financial strain, but we have persevered and succeeded together. My three kids – all grow’d up now – Julie had just turned two when we moved back to St. Louis – have been the greatest kids you can imagine. Each has made us very proud. Julie is the director of the entire youth program at Peterson Air Force Base in Colorado; Lynn is a family nurse practitioner; and when your hips or knees go out, you will want to talk to my son Mark who has had great success with his own company supplying primarily Smith and Nephew joint replacement parts. They are each here with me tonight. Part of the support system, but unable to attend today are Lynn’s husband Corey, and her two children, my grandchildren, Joey and Evie. Also, Mark’s wife Lizanne and their three boys Grant, CJ and Migel.

Again, I want to thank all of my colleagues for this honor. I appreciate the years I spent serving in the officer track of the Missouri Academy. I will say that during that time we had a fair amount of turn-over at the executive director level, but a key stabilizing force for me, and for the organization was our lobbyist Pat Strader. I am so sorry that Pat was unable to join us tonight. Our hearts ache with the health battles she having to endure, but our prayers are always with her, and for a recovery that will allow her to enjoy the retirement she so richly earned. Again, thank you.

MO-AFP.ORG 43

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Cole Assumes Helm of Missouri Chapter

“S

We may come from different places, bring different skill sets, or practice in different settings, but we are all walking the same path." arah Cole, DO, FAAFP, is the newly minted MAFP president and will serve through June, 2019. Kara Mayes, MD, introduced Dr. Cole.

Below are Dr. Mayes' remarks, along with Dr. Cole’s acceptance speech.

Dr. Kara Mayes’ Introduction: I am very pleased to introduce Sarah Cole as your next president of our academy. I am extremely honored to be able to take a few minutes this evening to introduce your next president of the Missouri Academy of Family Physicians. Sarah has been a role-model to me in many different ways, all of which will serve her well as our next president.

First, she is a great teacher. We first met almost 11 years ago, when I was a fourth-year medical student doing my sub-internship rotation at St. Johns Mercy where Dr. Cole was the inpatient service attending during one week of my rotation. After that rotation, I matched at St. Johns for my residency where she was our Associate Program Director. She taught me how to be a family physician, and perhaps just as importantly, how to be a great teacher.

She is also a great family physician. Her patients love her. Our office staff members enjoy working with her.

Although she has an overflowing patient panel, I’ve still managed to convince her to take on my kids, my mother, two of my aunts, and a few cousins as patients.

She is always willing to stay later and see more patients, in order to ensure her patients are well cared for.

I’ve also looked up to Sarah over the years as a leader. We’ve been able to serve together on the boards of both MAFP and the St. Louis Academy of Family Physicians. Her leadership style is one that I strive to emulate, as she somehow manages to keep groups on track while also allowing for all participants to contribute their ideas and passions.

Perhaps most importantly, she has been a rolemodel to me in the way that she balances her career with her life outside of work. She and her husband Matt have done a fantastic job so far in raising two kind, strong, and fun daughters, Emma and Sophie. She finds time to run, hike, and travel. And now I know she’ll do a great job of adding MAFP president into the mix. Sarah, thanks for being a teacher, a mentor, and a friend.

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

Dr. Cole listens as Kara Mayes, MD, introduces her.

Cole Acceptance Speech: My first words tonight are ones of gratitude. Thank you to Missouri’s family physicians for the care you provide daily to our state’s citizens. Thank you to the medical students and resident physicians who are embracing the call to do the same. Thank you to the MAFP Board of Directors, to its Executive Director, Kathy Pabst, and its staff Sarah Mengwasser and Becki Hughes for their passion, wisdom and guidance. Thank you to all our families for supporting our endeavors on behalf of family physicians and patients in the state of Missouri – you make sacrifices of your own so that we can do the work we do. My own husband Matt and my daughters Emma and Sophie are here today.

My family and I, with a montage of cousins and other extended family members, have made a hobby of backpacking and camping across our state. We leave our various homes across Missouri to meet at Hawn State Park in eastern MO, Prairie State Park in the west, Thousand Hills State Park in northern MO, or the mountains of the Ozark Trail in the south. As we hike, each person carries a pack on his or her back with items essential to our survival for the trip. Some items we carry for ourselves. Each individual, for example, carries his or her own water or own sleeping bag. But other items we carry are for the group. In one’s person’s pack is a tent, in another’s, food, in another’s the camp stove, and in another’s, the map and compass. We travel the same path, to the same destination, but carry with us different things, each one of which is

“

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Her leadership style is one that I strive to emulate, as she somehow manages to keep groups on track while also allowing for all participants to contribute their ideas and passions."

- Kara Mayes, MD

Dr. Sarah Cole with her husband, Matt and daughters Sophie and Emma.

necessary and none of which can be left behind at home if we are to succeed as a group. The same is true of MAFP and its membership. We may come from different places, bring different skill sets, or practice in different settings, but we are all walking the same path and that is summarized in MAFP’s mission: to optimize the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education, and research.

I have found this past year on the executive commission to be a curve – as steep as some mountains I’ve climbed -- in terms of learning who is traveling the path of family medicine in our state. I commit to the diversity of our membership: MDs and DOs, graduates of domestic and international medical schools, students and residents, physicians who are in direct practices or FQHCs, physicians who are self-employed, clinicor hospital-employed, those who work part-time or full-time, in clinical or non-clinical roles, those who are military or veteran, those who serve patients in urban areas, rural areas or both, those who teach the next generations of physicians, those who practice a range of traditional clinical skills and those who may focus on a critical niche. The family physicians in our state are an incredibly diverse group. I am humbled to serve as your representative and I pledge to listen to you so that MAFP can work to facilitate your needs.

One of the most illuminating things I’ve found while hiking across our state is talking with other people we meet coming down the same trail, taking a few moments to pause, to greet them and ask where they’re from, why they’re here, and what the trail’s like from the other direction. Not only is it inspiring to hear the reasons other people have come to the trail, we also

often learn important information -- is there a water source ahead or are the trail markers hard to find — information that potentially changes our future actions or alters the course of our direction. And so, I’d like to pause and greet some of our members this year, as well. I know how hard it is for physicians, particularly family physicians in critical roles or areas, to take time away from their patients or their daily work. And so, I am committing to come to you. Over the coming year, I hope to visit all ten delegates, ideally with one or more of their colleagues or other designees, their staff or their patients in their home districts. I’d like to see their practices or employment sites, hear their challenges and share their successes and then I want to bring their stories to all MAFP members by blogging them via MAFP. Additionally, if you are a member who can be physically present at the Annual Fall Conference in November or the Show Me Family Medicine Conference in June, at Advocacy Day in February, or at the upcoming strategic planning session in August, then I encourage you to be there, to tell your own story and thus shape MAFP’s actions and direction. You are carrying tools as an individual that strengthen what we, as a group of family physicians, can do together. You can share your experiences with others as we work to reduce the challenges associated with optimizing health care in Missouri and to replicate the successes.

In closing, my goal for the year is this: to honor the work and mission of the family physicians who have walked this trail before us as we commit to strategies that help family physicians bridge health care gaps now and in the future. Thank you.

MO-AFP.ORG 45

Worried about

MIPS for 2018?

SHINE of Missouri participants enjoy: • A physician-led, secure Health Information Network that allows patient information to be shared among connected patients, physicians, health care facilities, and other health care providers.

• A CMS-approved Qualified Clinical Data Registry (QCDR) called the “Doctors Quality Reporting Network.” Through the QCDR we collect and submit Quality (via eCQMs), Advancing Care Information (now known as Promoting Interoperability), and Improvement Activities for MIPS. • Hands On-Technical Support from SHINE representatives available to meet with you in person, via webinar, phone, or by email.

To learn more about SHINE of Missouri please contact:

Jonathan Smith

In partnership with Missouri State Medical Association

844.424.4370 In partnership with Missouri State Medical Association

Regional Manager SHINE of Missouri 844.424.4370 jsmith@SHINEofMissouri.com

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Meet Your New Officers

T

he Missouri Academy of Family Physicians (MAFP) installed new officers during the Awards and Installation Dinner in conjunction with MAFP’s 70th Annual Meeting in Camdenton, Missouri, on June 8, 2018. Serving as President last year, Mark Schabbing, MD, of Perryville, Missouri, subsequently became Board Chair. Other officers installed were Sarah Cole, DO, FAAFP, President, Chesterfield; Jamie Ulbrich, MD, FAAFP, President Elect, Marshall; John Paulson, DO, PhD, FAAFP, Vice President, Joplin, and Lisa Mayes, DO, Secretary/ Treasurer, Macon.

Mark Schabbing, MD, of Perryville, is employed by the Perryville Family Care Clinic, where he is also a partner. He graduated from University of Missouri-Columbia School of Medicine and completed his residency there as well. He is married to Tracey and they have two daughters, Linden and Sydney, and a son, William.

Sarah Cole, DO, FAAFP, of Chesterfield, was given the presidential oath by Kara Mayes, MD. Dr. Cole is employed as the program director of Mercy Graduate Medical Education where she supervises the program’s Pediatrics, Community Medicine, and Osteopathic Manipulative Treatment curriculum. Dr. Cole graduated from Kirksville College of Osteopathic Medicine and completed residency at Mercy Family Medicine Residency. Dr. Cole is married with two daughters.

Jamie Ulbrich, MD, FAAFP, of Marshall, has been practicing medicine for over 25 years and is the owner of Ulbrich Family Medicine, LLC, in Marshall. He is board certified in family medicine and a Fellow of the American Academy of Family Medicine. He graduated from University of Missouri Columbia School of Medicine and completed his residency at John Peter Smith Hospital Family Practice Residency Program. Dr. Ulbrich is married to Sherri and they have two daughters and one son.

John Paulson, DO, PhD, FAAFP, of Joplin, Missouri, is the Interim Chair of Primary Care at the Kansas City University of Medicine and Biosciences, Joplin Campus. He is board certified in family medicine and a Fellow of the American Academy of Family Physicians. He graduated from Oklahoma State University Center of Health Sciences and completed his residency at Cox Family Medicine Residency in Springfield, MO. Dr. Paulson is married to Crissy and they have one daughter.

Lisa Mayes, DO, of Macon, is employed by the Samaritan Hospital in Macon, Missouri and has been practicing for 10 years. She is board certified in family medicine. She graduated from AT Still University in Kirksville and completed her residency at Northeast Regional Medical Center in Kirksville, MO. Dr. Mayes is married to Shane, for nearly 12 years, and they have three daughters.

Up to 17.25 CME hours

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Ryan McDonough, DO

MO-AFP.ORG 47

MEMBERS IN THE NEWS Top Graduating Medical Student The Family Health Foundation of Missouri presented its annual 'Top Graduating Medical Student Entering a Missouri Family Medicine Residency' awards again this year. Each medical school is asked to identify the student who then receives a certificate of recognition and $500. Congratulations on a job well done, and best wishes for a successful residency! This year’s recipients are: Name John Heafner Taylor Allen Mindy Guo Colin McDonald Ziva Patt-Rappaport Peter Lazarz

Medical School St. Louis University AT Still University Washington University University of Missouri Columbia Kansas City University University of Missouri Kansas City

Missouri Residency St. Louis University Capitol Region Medical Center St. Louis University University of Missouri Columbia Research Medical Center University of Missouri Kansas City

Summer Externship Recipients Announced Medical students interested in family medicine were selected to participate in summer externships.

This year’s recipients are: Matthew Decker received his undergraduate degree from Truman State University in Kirksville and is a fifth year medical student at University of Missouri Kansas City. His externship experience will be held at University of Missouri Columbia Family Medicine Residency.

Morgan Dresvyannikov is a fourth year medical student (in a six-year program) at University of Missouri Kansas City, and is dually enrolled in their undergraduate biology program. University of Missouri Kansas City Family Medicine Residency is also the site of her externship training.

Mitchell McCord is a third year medical student at Kansas City University of Medicine and Biosciences. He earned his undergraduate degree from Xavier University. He is completing his externship at Mercy Family Medicine Residency.

We hope these medical students fall in love with family medicine and become future Missouri family physicians! Look for more about their externship experiences in the next issue of the Missouri Family Physician magazine.

Family Medicine Leads Scholarships Three students from Missouri Family Medicine schools were recognized by the AAFP for their interest in family medicine and commitment to providing patient-centered care. Each winner received a $600 scholarship provided by the AAFP Foundation to attend the National Conference of Family Medicine Residents and Students, August 2-4, in Kansas City. The recipients are: Kristia Abernathy, MS-3, Saint Louis University Amisha Parikh, MS-1, Washington University Adam Reinagel, MS-3, Saint Louis University

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

NEWS TO SHARE?

The Missouri Family Physician magazine welcomes your input!

Please submit newsworthy items for review to: office@mo-afp.org

Larsen, AAFP Resident Delegate to the AMA, Delegate to HOD Kaci Larsen, MD, University of Missouri, Columbia, was the AAFP resident delegate to the American Medical Association (AMA) Resident and Fellow Section (RFS) and attended the annual meeting in Chicago. Larsen also served as a delegate to the House of Delegates.

As the RFS delegate, Larsen worked with resident/fellow colleagues across the country to create policy within their section they felt strongly about. Some of these issues included access to care, ownership and sale of medical data, eliminating barriers for medical students/residents with disabilities.

In the larger HOD, topics such as prevention of gun injuries/deaths, gender pay disparities in health care, and opposition of separating children and parents at the border.

They also heard from the Surgeon General, Dr. Jerome Adams, whom Larsen had the pleasure of meeting.

Larsen and Surgeon General, Dr. Jerome Adams.

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MO-AFP.ORG 49

AUGUST 17-18, 2018 Jefferson City, Missouri

Are you ready for the next step in your career, whether a third or fourth year medical student or resident? Years of planning and education have brought you to where you are today as you transition to practice as a Missouri family physician.

This Missouri Academy of Family Physicians' Transition conference will provide resources and practical tools to Missouri family medicine residents and students as you begin your careers after residency. Participants will experience a welcoming environment to exchange information and ideas with fellow residents, students, and physicians during this two-day interactive conference.

What will you learn?

• Leadership skills essential to performing well in your role • Resources as well as valuable peer and family medicine expert connections • The power of engagement at the community, state, and national levels • Balancing school, work, and family to prevent burnout

Visit mo-afp.org/cme-events to view the schedule and to register COMPLIMENTARY REGISTRATION AND LODGING AVAILABLE

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mily Lott, MD, President of the Kansas City Chapter of the MAFP, earlier this year requested a donation to help offset the costs of students to attend conferences where they make presentations on projects and research they have been involved in. This was an excellent opportunity to promote the specialty of family medicine amongst medical students at the local medical schools in Kansas City. The Family Health Foundation of Missouri supported their efforts with a $600 donation. Below is some of the feedback from those who attended these conferences:

"This was my first time attending a medical conference since I started at UMKC, and I learned so much more than I expected!

The conference made me even more proud of our own student-run free health clinic and I have many of ideas of how I want to improve it. Thank you so much for your help!"

- Shruti Kumar, UMKC MSII

"I would like to thank you sincerely for providing us with the opportunity to attend the 2018 Society for Student Run Free Clinics conference in Omaha. This conference was a valuable learning opportunity for us and I personally learned a lot of ideas on how we can keep improving Sojourner Health Clinic in order to better serve our Kansas City community. I hope to implement some of these ideas in the clinic; and by doing so, use your contributions as a springboard to give back to our great community."

- Sriram Paravastu, PR Officer, Sojourner Health Clinic

Help Support FHFM

Contact the MAFP office today! office@mo-afp.org or 573.635.0830

"Thank you so much for allowing me to attend the SSRFC conference this year. It was my first time going and I was immensely inspired by all the clinics attending from across the country. Our team left Omaha full of ideas and projects that we can't wait to get started on to make our clinic better and even more successful. I truly enjoyed the experience and look forward to networking with other clinics, learning more about SRFCs, and expanding our clinic for years to come."

- Eshwar Kishore, Sojourner Webmaster

"Having attended this conference for the third time in four years, this was probably our best year by far. The team of students tackled the presentations with a vigor, ensuring someone attended each talk we were interested in. Their passion was evident as they talked a million miles an hour about the talk they attend, what they learned from it, and what idea they had to implement within Sojourner Health Clinic.

The presentations from our students were well attended and initiated discussion between various professions from around the United States. None of this would have been possible without your contribution.

From everyone who attended the conference and everyone that will benefit from the ideas that came from the conference, thank you."

- Peter Lazarz, Executive Director, Sojourner Clinic

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MISSOURI FAMILY PHYSICIAN JULY-SEPTEMBER 2018

MAFP Board Chair Sends Letter of Support On behalf of the 2,400+ members of the MAFP, Mark Schabbing, MD, board chair, wrote a letter to support continued use of fluoridation of the water supply for the City of Houston’s 2,000 citizens. His letter stated, that “benefits outweigh the long-term health impact of not providing this service to your community. As Family Physicians, we see how poor dental health in communities without CWF effects other health issues for children and adults.

According to the American Academy of Family Physicians, “Systematic Evidence Review of Community Water Fluoridation” (2013), there is high quality evidence that CWF programs reduce caries in children and adults. The presence of fluoride in community water supplies results is lower levels of caries, the addition of fluoride reduces the number of caries within a short period of time and the elimination of fluoride from a community water supply increases the number of caries within a short period of time. These results have been consistently found regardless of the date of the analysis showing that benefits persist even in an era of availability of fluoride from other sources. There is moderate certainty that CWF causes tooth mottling in a small proportion of the population, which can have cosmetic consequences but no other known harm. There currently is no credible evidence of any other harms from CWF.

MO-AFP.ORG 53

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