Pain Management - CME Eligible

FP Pain FALL 2023

MISSOURI FAMILY PHYSICIAN VOLUME 42, ISSUE 4

Management NO PAIN

MILD PAIN

MODERATE PAIN

SEVERE PAIN

Up to 3.0 CME Credits Available in This Issue

WORST PAIN

Hypophosphatasia by Hypophosphatasia(HPP) (HPP)isis aa metabolic metabolic disorder disorder characterized characterized by 11 LOW LOWAlkaline AlkalinePhosphatase Phosphatase (ALP) (ALP) activity activity Patients Patientswith withHPP HPP may may experience experience unpredictable, devastating, devastating,and andlife-limiting life-limiting consequences, consequences, including:11 SHORT SHORTSTATURE STATURE AND/OR AND/ORUNUSUAL UNUSUAL GAIT GAIT

PREMATURE PREMATURE TOOTH TOOTHLOSS LOSS

• •InInadults, adults,low lowALP ALPactivity activityisis<40 <40U/L U/L2,a2,a

MUSCLE MUSCLEWEAKNESS WEAKNESS AND/OR AND/ORFATIGUE FATIGUE

CHRONIC CHRONIC MUSCLE/ JOINT PAIN

SKELETAL SKELETAL DEFORMITIES AND/ AND/ DEFORMITIES OR FRACTURES FRACTURES OR

•• Agein children children3.43.4 Age-and andsex-adjusted sex-adjustedALP ALPreference reference intervals must be used in

Patientswith withany any of of these these key key signs/symptoms Patients andLOW LOW ALP ALP should should be be evaluated evaluated for HPP1 and a Example cutoff from Abbott Laboratories; adult ALPranges rangesare arelab labspecific specificand andmay mayvary. vary.

Example cutoff from Abbott Laboratories; adult ALP

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References: 1. Bishop N, al. et al.

Arch Child . 2016;101(6):514-515.

Alkalinephosphatase phosphatase[package [packageinsert]. insert].Abbott AbbottPark, Park,IL: IL:Abbott AbbottLaboratories; Laboratories; 2007.

2007. 3.

3. Offiah Offiah AC, AC, et References: 1. Bishop N, et Arch DisDis Child . 2016;101(6):514-515.

2.2.Alkaline et al. al. Pediatr Pediatr Radiol Radiol.. 2019;49(1):3-22.

2019;49(1):3-22.

Chem . 2012;58(5):854-868.

4. Colantonio et Clin al. Clin Chem . 2012;58(5):854-868.

4. Colantonio DA,DA, et al.

LOWAlkaline AlkalinePhosphatase Phosphatase(ALP) (ALP)may may not not be be flagged flagged ifif your your laboratory laboratory does LOW does not not use use 1 age-and andsex-adjusted sex-adjustedreference referenceintervals intervals in in children children when when testing testing ALP ageALP activity activity1 2,3 Age-and andsex-adjusted sex-adjustedALP ALP reference reference ranges, ranges, U/L U/L2,3 Age-

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Normal ALP Normal ALP Low ALP in pediatric females and males Low ALP in pediatric females and males Low ALP in adults Low ALP in adults

NOTE: Graph adapted from the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) project. 2 Caliper samples from 1072 male and 1116 female participants (newborn to 18 years) were used to NOTE: Graph ageadapted the Canadian Laboratory on Pediatric Reference Intervals (CALIPER) project. 2 Caliper samples fromshown 1072were maleestablished and 1116 female (newborn to 18 analyzer. years) were used to calculate and from sex-specific reference intervals.Initiative No variation in ALP based on ethnic differences was observed.

Reference intervals on theparticipants Abbott ARCHITECT c8000 calculate andprovided sex-specific reference intervals. No variation ALP based sheet on ethnic intervals shown ages, were established Abbott ARCHITECT a Adult ageinterval by the Abbott ARCHITECT ALP productininformation is fordifferences females >15was andobserved. males >20Reference years of age.

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Adult interval provided by the Abbott ARCHITECT ALP product information sheet is for females >15 and males >20 years of age. For younger ages, Abbott does not provide lower limits of normal.3

LOW Alkaline Phosphatase (ALP) is hallmark of Hypophosphatasia.1 LOW Alkaline Phosphatase (ALP) hallmark of Hypophosphatasia.1 To learn more, please visitiswww.hypophosphatasia.com To learn more, please visit www.hypophosphatasia.com

References: 1. Rockman-Greenberg C. Pediatr Endocrinol Rev. 2013;10(2 suppl):380-388. 2. Colantonio DA, et al. Clin Chem. 2012;58(5):854-868.

3. Alkaline1.phosphatase [package insert].

Abbott Park, IL:Rev Abbott Laboratories; 2007.

References: Rockman-Greenberg C. Pediatr Endocrinol . 2013;10(2 suppl):380-388.

2. Colantonio DA, et al. Clin Chem. 2012;58(5):854-868.

3. Alkaline phosphatase [package insert]. Abbott Park, IL: Abbott Laboratories; 2007.

2

Please contact Amy.Flinn@alexion.com Please contact to learn more Amy.Flinn@alexion.com information about hypophosphatasia. to learn more information about hypophosphatasia.

MISSOURI FAMILY PHYSICIAN October - December 2023

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION BOARD CHAIR John Burroughs, MD (Kansas City) PRESIDENT Kara Mayes, MD, FAAFP (St. Louis) PRESIDENT-ELECT Afsheen Patel, MD (Kansas City) VICE-PRESIDENT Natalie Long, MD (Columbia) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1

DIRECTOR Arihant Jain, MD (Cameron) ALTERNATE Vacant DISTRICT 2 DIRECTOR Eric Lesh, DO (Kirksville) ALTERNATE Vacant DISTRICT 3 DIRECTOR Dawn Davis, MD (St. Louis) DIRECTOR Lauren Wilfling, MD (St. Louis) ALTERNATE Christian Verry, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald) ALTERNATE Jennifer Allen, MD (Hermann) DISTRICT 5 DIRECTOR Amanda Shipp, MD (Versailles) ALTERNATE Misty Todd, MD (Sedalia) DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville) ALTERNATE Justin Cramer, MD, FAAFP (Marshall) DISTRICT 7 DIRECTOR Beth Rosemergey, DO, FAAFP (Kansas City) DIRECTOR Jacob Shepherd, MD, FAAFP (Lee’s Summit) ALTERNATE Ed Kraemer, MD (Lee’s Summit) DISTRICT 8 DIRECTOR Andi Selby, DO (Branson) ALTERNATE Barbara Miller, MD (Neosho) DISTRICT 9 DIRECTOR Douglas Crase, MD (Licking) ALTERNATE Vacant DISTRICT 10 DIRECTOR Gordon Jones, MD (Sikeston) ALTERNATE Jenny Eichhorn, MD (Jackson) DIRECTOR AT LARGE Wael Mourad, MD (Jefferson City) Krishna Syamala, MD (St. Louis)

RESIDENT DIRECTORS Kelly Dougherty, MD, Mercy Noah Brown, MD, Mercy (Alternate)

STUDENT DIRECTORS

CONTENTS 4 The Pain Management Issue and Special Message from the Outgoing Board Chairman 6 Five Practical Strategies for Managing Pain in Patients with Opioid Use Disorder on Buprenorphine 8 Pain, Cannabis, and Safety in a Recreational Cannabis State 10 Now You Too Can Treat Opioid Use Disorder 16 Management of Tendinopathy 20 Case Study: OMT Low Back Pain2023 Recommended 22 Case Study: An Osteopathic Approach to Temporomandibular Joint Pain 24 Reflections from the 2023 Summer Externs 27 Missouri AFP Participates in National Conference 29 MAFP Starts a Family Medicine Residency Collaborative 30 GME: We are Expanding in Missouri 32 Members in the News 33 Resident Composites 44 References 47 31st Annual Fall Conference Registration Form

MARK YOUR CALENDAR

AAFP DELEGATES

October 20-22, 2023 Physician Wellness Seminar Margaritaville at Lake of the Ozarks https://www.maops.org/general/custom.asp?page=wellnessseminar

Kate Lichtenberg, DO, MPH, FAAFP, Delegate Peter Koopman, MD, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Jamie Ulbrich, MD, FAAFP, Alternate Delegate

November 10-11, 2023 31st Annual Fall Conference & Annual Meeting Big Cedar Lodge, Ridgedale, MO https://www.mo-afp.org/cme-events/afc/

Abby Crede, UMKC Mikala Cessac, UMC (Alternate)

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank, CAE MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational 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 opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

November 12, 2023 MAFP Commission and Board of Directors Meetings Big Cedar Lodge, Ridgedale, MO February 26-27, 2024 MAFP Advocacy Day Courtyard Marriott, Jefferson City https://www.mo-afp.org/advocacy/advocacy-day/ February 27, 2024 MAFP Board of Directors Meeting Courtyard Marriott, Jefferson City (in-person & virtual)

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org MO-AFP.ORG 3

The Pain Management Issue and Special Message from the Outgoing Board Chairman

W

elcome to the Missouri Family Physician Missouri Family Physician. We have articles ranging Pain Management issue. Do you already from procedural treatment of pain including OMT and treatment of tendinopathies, the ever-expanding feel uncomfortable? Treatment of pain availability of cannabis for our patients, and the is one of the most foundational roles use of buprenorphine. Opening and adding to our in our profession. Yet, there is more uncertainty than toolbox can only strengthen our ability to help our ever in how to assess, measure, and treat pain, let patients in their most basic need: the need to feel alone an entire field that has risen in managing those less suffering. How we do that seems to be more who have become dependent on pain medications. confusing and contentious all the time. The best Pain management stands alone in infringing on the medicine for confusion and contention sacred idea of patient-physician is always information and openness. trust. Physicians rightfully set very OPENING John Burroughs, MD, FAAFP specific guidelines on what kind, It is what we do best as family Board Chair physicians. duration, and severity of pain they AND ADDING TO This column also brings the end Liberty, MO treat. Healthcare systems can be OUR TOOLBOX CAN of my time as Chair of the MAFP even more stringent in defining how their clinicians manage and ONLY STRENGTHEN Board of Directors into closer focus.

These four years on the board’s don’t manage acute and chronic OUR ABILITY TO executive commission have been pain. Additionally, governmental HELP OUR PATIENTS such an amazing time of professional regulation of clinical care of pain growth for me as a physician. It has has been a hot-button issue in our IN THEIR MOST provided me the opportunity and the state throughout my eight years on BASIC NEED: THE tools to help our family physicians the Board of Directors for the MAFP. in Missouri take care of the citizens I have recently spent two NEED TO FEEL LESS in Missouri in ways that I could not wonderful years working full-time SUFFERING conceive of without stepping outside in outpatient and inpatient hospice of the confines and comforts of just and palliative care and have just the office practice setting. I have been able to do returned to office family medicine with a part-time such cool things and meet such inspiring physicians hospice role. It felt like an idyllic return to purity in throughout our state and nation. I cannot thank our pain management. These patients, these people, academy staff of Kathy, Bill, and Brittany enough for were dying and they were uncomfortable. I grew the knowledge, mentorship, and patience with all more comfortable with prescribing higher doses of our board members - especially me! Thank you of narcotics more frequently thanks to the close to those previous leaders of the MAFP that I have relationships with, and frequent monitoring of, the marveled at and learned from. And a huge thank patients’ symptoms and response to treatment. I you to all of you, Missouri’s family physicians, for even became more proficient with and appreciative of methadone (gasp!) in treating severe chronic pain. the amazing and inspiring work that you do for your patients. Keep reading and keep staying active (and And, as always, I learned that not all patients (or maybe become more active?) in the work of our pain) are the same. I would fall very short of the goal Academy. Our physicians and our patients need you. of relieving suffering if I used only narcotics to treat pain in these patients.

Coming from that practice environment, I am so excited by the breadth of topics in this issue of the

Mission Statement:

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.

4

MISSOURI FAMILY PHYSICIAN October - December 2023

CME Credit Available in This Issue

T

he AAFP has reviewed Pain Management Articles in Missouri Family Physician Magazine and deemed it acceptable for AAFP credit. Term of approval is from 10/01/2023 to 10/01/2024.

Physicians should claim only the credit commensurate with the extent of their participation in the activity. The articles on pages 6, 8 and 10 have been approved for 1.0 Enduring AAFP Prescribed credit each.

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

In order to claim your CME credit, please fill out the form at https://moafp.formstack. com/forms/pm_cme. Contact Bill Plank with any questions at bplank@mo-afp.org.

SPRINGFIELD MISSOURI

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FIVE PRACTICAL STRATEGIES FOR MANAGING PAIN IN PATIENTS WITH OPIOID USE DISORDER ON BUPRENORPHINE

Kento Sonoda, MD, FASAM, AAHIVS Assistant Professor, Department of Family and Community Medicine Saint Louis University St. Louis, MO

SEE PAGE 5 FOR DETAILS. 6

MISSOURI FAMILY PHYSICIAN October - December 2023

I

n the United States, more than 46 million people aged 12 or older had a substance use disorder (SUD) in the past year, including 5.6 million people with opioid use disorder (OUD), according to the latest National Survey on Drug Use and Health.1 In Missouri, a total of 11,750 individuals were admitted to the Division of Behavioral Health substance use disorder treatment programs due to OUD in the fiscal year 2022.2 It is reported that patients with OUD commonly have occurring chronic pain and mental disorder.3,4 Given the prevalence of OUD and the need of multidisciplinary approach for complex care, family physicians are well-suited to address pain in patients with OUD in the ambulatory setting.

Among the three FDA-approved medications for OUD, buprenorphine stands as the most pertinent choice with robust evidence, and it can be prescribed by family physicians in their clinics. Buprenorphine is a partial mu-receptor agonist and a kappa-receptor antagonist and has been commonly used for treating OUD with significant benefits on all-cause and opioid-related mortality.5 Buprenorphine has a higher affinity for the mu-receptor than other opioids, which can complicate pain management in patients on buprenorphine, especially when opioid analgesics are used for severe pain.

This complexity might lead to undertreatment of pain by clinicians due to unfamiliarity with how to manage the complicated pain.6,7 This article introduces five practical strategies to help family physicians feel more comfortable managing pain in patients taking buprenorphine.

FIVE PRACTICAL STRATEGIES TO MANAGE PAIN IN PATIENTS WITH OUD ON BUPRENORPHINE Utilize a non-pharmacological approach:

Increase the frequency of buprenorphine:

Buprenorphine has been typically prescribed as BID (or QD) for the maintenance of OUD. The frequency of QD or BID perfectly works for the maintenance treatment given the duration of suppression for opioid withdrawal for 24 to 48 hours. However, buprenorphine only provides a potent analgesic effect for 4 to 8 hours. For instance, you can change buprenorphine 8 mg BID to 4 mg QID for better managing chronic pain. At the follow-up visit, you can adjust the dosage based on craving or withdrawal symptoms as well as pain level. For acute pain, you can consider adding extra buprenorphine 2-8 mg on top of regular dosing. Due to the breadth of this article, I defer elaborating further on acute pain management to other articles.12

Address comorbid mood disorders:

Many individuals with OUD develop other mental disorders, and vice versa. Common mental disorders include major depressive disorder, generalized anxiety disorder, attention-deficit hyperactivity disorder, and bipolar disorder.13,14 As mental disorders and OUD were strongly connected, concurrent treatment would be preferable through the integrated approach instead of stabilizing either condition first with holding off the treatment of the other condition.15 Family physicians are well-suited to provide integrated care of behavioral health and SUD care.

interrupting buprenorphine treatment puts patients at high risk for relapse

Several complementary or integrative treatment options are available to treat common chronic pain. Examples of the non-pharmacological approach include acupuncture, mind-body interventions (e.g., cognitive behavioral therapy, yoga, tai chi), and exercise.

To learn more details, you can read an excellent review article, “Complementary/Integrative Therapies That Work: A Review of the Evidence.”8

Maximize non-opioid analgesics:

with moderate to severe chronic back pain or hip or knee osteoarthritis.10 The Centers for Disease Control and Prevention also supports non-opioid management for common types of pain.11

Various non-opioid analgesics (e.g., acetaminophen, NSAIDs, antidepressants, topical lidocaine) are safe and effective medications to manage mild to moderate pain, even for severe pain.9 For instance, a 2018 randomized clinical trial showed that opioid analgesics were not superior to non-opioid medications for improving pain-related function over a year in patients

Continue buprenorphine throughout the surgical course:

Please note that discontinuation of buprenorphine is not required prior to a planned surgery since various analgesic options are available to manage the pain related to surgery in patients taking buprenorphine.16-19 You can continue buprenorphine in the perioperative setting instead of holding off buprenorphine before surgery.20 Furthermore, interrupting buprenorphine treatment puts patients at high risk for relapse. During the follow-up visit after surgery, you can consider providing short-term opioid treatment for acute postoperative pain if needed.

Buprenorphine has been commonly used and expected to increase, given the waiver elimination effective in June 2023.21 It is critically important for family physicians to become familiar with pain management in patients on buprenorphine and provide evidence-based practice to our community.

References on pages 44-45.

MO-AFP.ORG 7

Pain, Cannabis, and Safety in a Recreational Cannabis State SEE PAGE 5 FOR DETAILS.

T

Sheryl Lyss, MD, MPH Saint Louis University School of Medicine, Addiction Medicine Fellow St. Louis, MO

he people of Missouri voted to approve the use of cannabis for recreational purposes in 2022, following a previous referendum to approve cannabis for medical use in 2019. Marijuana remains illegal at a federal level, and its position as a Schedule 1 drug makes research, recommendations, and education difficult. As a result, legalization by individual states and commercialization have outpaced the development of evidence, clinical information, or recommendations to guide the use of cannabis for treating medical conditions. Thus, many family physicians are challenged to provide patient advice regarding cannabis for recreational or therapeutic use.

This article briefly explores what we know and what we are learning about cannabis, particularly with regard to its use for pain, how the legalization of recreational and medical cannabis changes the landscape for family physicians and their patients, and how family physician can help patients mitigate risks of cannabis use.

Cannabis and medical use

John Hartman Saint Louis School of Medicine, Medical Student, Class of 2024 St. Louis, MO

Fred Rottnek, MD SSM Health SLUCare and Saint Louis University School of Medicine, Family Medicine, and Addiction Medicine St. Louis, MO 8

MISSOURI FAMILY PHYSICIAN October - December 2023

Cannabis contains over 100 different cannabinoids, including tetrahydrocannabinol (THC) and cannabidiol (CBD), which directly affect the endocannabinoid system and terpenes which are aromatic compounds responsible for its scent and taste.1 THC is the main psychoactive compound that is responsible for the “high” associated with cannabis use. If a cannabis plant contains ≥0.3% THC, the product is typically called marijuana; if the THC level is <0.3%, the product is hemp which has no restriction on growth or sales in the United States.2 The potency or concentration of THC in cannabis products has been increasing over the past decade because of changes in production (e.g., crossbreeding to produce cannabis cultivars with increased THC concentrations) and the use of cannabis extracts and synthetic products.3,4 Various derivatives of the cannabis plant have been used for centuries to treat pain, nausea, anxiety, depression, insomnia, and other medical conditions.

A recent survey of 9003 adults identified the most common medical reasons for using cannabis as anxiety (49%), insomnia (47%), chronic pain (42%) and depression (39%).5 Patients today often seek information about cannabis from the web and through social media. Such information often portrays cannabis as a natural and safe remedy for many health conditions; yet the information provided is often anecdotal and not evidence based.6

What is the new cannabis amendment in the Missouri constitution?

Missouri Amendment 3, the Marijuana Legalization Initiative, was approved by voters in November 2022.7 It expands parameters of accessing marijuana for therapeutic use and legalizes recreational marijuana use for individuals over the age of 21. Patients certified for medical marijuana can now purchase and

possess 6 ounces of marijuana; those using recreationally can purchase and possess 3 ounces. In addition to physicians, nurse practitioners can now certify patients for medical marijuana.

Medical marijuana has a 4% tax rate. In contrast, recreational marijuana is taxed at 6%. Local governments may impose an additional sales tax of up to 3% on marijuana sales.

Additional aspects of the amendment include expungement of certain marijuana-related offenses and regulations regarding licensing of marijuana facilities, marketing and advertising, local control of marijuana use and facilities, and future rules for testing marijuana products.8

What do we know and what are we learning about cannabis and pain?

Multiple studies have been conducted to assess the effect of cannabis on health conditions. Although a few cannabis products (plant derivatives or synthetic products) have been FDA-approved for very specific indications (such as dronabinol or nabilone for cancer chemotherapy-induced nausea and Epidiolex, which contains a purified form of CBD, for the treatment of seizures associated with Lennox-Gastaux or Davet syndrome in children aged ≥2 years),9 cannabis remains illegal at the federal level, limiting research on its potential benefits and adverse effects.10 Even data from meta-analyses, systematic reviews, and placebocontrolled trials have often been considered low-quality, and findings conflict across studies. The use of various cannabis products and delivery routes limit the comparability of the studies, and findings are not generalizable to cannabis purchased from dispensaries or on the streets. Importantly, few studies have compared cannabis with other analgesics, whether over the counter (such as NSAIDs or acetaminophen) or with prescription medications, including opioids.

For example, cannabis has been studied as a treatment for acute or post-operative pain,11 cancer pain,12 neuropathic pain,13 rheumatologic pain,14 and other non-cancer, chronic pain.15,16 Current evidence suggests that cannabis may have a small to moderate effect in reducing the severity of neuropathic pain, though data have generally been considered to be of low quality.17,18,19 Cannabinoids appear to have minimal efficacy in treating rheumatic or musculoskeletal pain,20,21 though one prospective observational study demonstrated a significant decrease in pain intensity among patients with fibromyalgia.22 Cannabinoids have had some analgesic effects as adjuvants to opioids in the treatment of cancer pain, but did not decrease opioid consumption in patients.23 Although some low-quality studies suggest that cannabis might have a small effect on reduction of acute pain,24 existing literature do not support using cannabinoids for acute or post-operative pain.25

What do we need to caution patients about regarding drug interactions?

Even for studies in which a mild to moderate analgesic effect of cannabis was demonstrated, authors typically cautioned that data were insufficient to recommend cannabis for treatment of pain, in part because the frequency of mild to moderate adverse effects might outweigh any benefit. In one systematic review of studies of cannabinoids for the treatment of chronic, non-cancer pain, adverse events reported among participants in 35 studies included dizziness (31%), fatigue (15%), increased appetite (15%), nausea (13%), and hallucinations (13%).26 In a meta-analysis of six trials of cannabinoids for the treatment of acute pain, the incidence of dizziness and hypotension was statistically significantly greater in the cannabinoid than control groups.27 Additionally, hepatic metabolism of THC and CBD variously inhibits or induces specific cytochrome P450 enzymes, leading to increased or decreased

levels of medications taken concurrently; important interactions include with anticoagulant and antiplatelet medications, opioids, nonopioid analgesics, antidepressants, antipsychotics, antiarrhythmics, anticonvulsants, and other medications.28

How do we educate patients to reduce potential harm related to use?

Despite limitations of current research on the potential health benefits and risks of cannabis, honest and open discussions between family physicians and their patients about cannabis use are vital for reducing potential harms. An important starting point for these discussions is understanding why and how patients are using cannabis.

The primary routes of cannabis use are smoking, vaping, and taking edible forms of cannabis. Smoking can take the form of using hand-rolled papers (joints), emptied cigars or cigarettes that are filled with cannabis (blunts), or glassware (pipes which are called bong bowls). Vaping involves dissolving cannabis extracts in a volatile solution that is heated and inhaled. In edible forms, cannabis extract is mixed into baked goods, candies, or beverages.

These products can be purchased by any adult above the age of 21 in Missouri dispensaries.

An important framework for discussions between patients and providers is harm reduction, which aims to limit the negative consequences of cannabis use while promoting safety. History taking of cannabis use should be approached non-judgmentally to enhance patient trust. Taking a detailed history of a patient’s cannabis use should include frequency, route of use, dosage, and location where the cannabis is procured. Fortunately, dispensaries in Missouri provide the potency (percent THC) and the dosage (amount of THC). For patients who choose to purchase medical or recreational cannabis from dispensaries, physicians can reinforce that decision by explaining that cannabis purchased at dispensaries is somewhat regulated which is not true for cannabis purchased on the street.

In the spirit of harm reduction, many experts advise patients to avoid combustible products and to choose vaping or edible products to decrease adverse respiratory effects; however, caution is warranted with edibles because the delay in onset of psychoactive effects may diminish the user’s ability to titrate the dose. Using cannabis daily or near daily and using products with higher THC concentrations are both associated with greater risk of acute and chronic adverse health outcomes, including mental health problems and dependence.29 As with any psychoactive substance, less of a product generally translates to safer use. There is no standard dose of marijuana but starting lower or advising lower use can be beneficial. Encouraging patients to track and log the amount and type of cannabis they consume gives a provider a picture of patient’s use over time. Additionally, patients who endorse using cannabis to relieve pain, anxiety, insomnia, or other symptoms can be encouraged to track the benefits and side effects that they experience with various products and amounts of use.

Helping our patients stay safe until we all know better

With the passage of Amendment 3, individuals who had not previously obtained certification for medical marijuana may be more likely to purchase adult-use cannabis from a dispensary.

Whether or not physicians certify patients for medical marijuana, physicians still have an important role in discussing what is known and what we are learning about both the health benefits and adverse effects of cannabis.

References on pages 44-45.

MO-AFP.ORG 9

Now You Too Can Treat Opioid Use Disorder SEE PAGE 5 FOR DETAILS.

O

n December 29, 2022, with the signing of the Consolidated Appropriations Act of 20231 (the Act), Congress eliminated the “DATA-Waiver Program.”2 No longer are physicians required to receive the DATA 2000 DEA buprenorphine X Kurt R. Bravata, M.D. FASAM waiver in order to treat opioid use Family and Addiction Medicine disorder (OUD). This was a huge milestone in addiction treatment Citizens Memorial Healthcare which effectively removed a Bolivar, MO significant barrier to treating patients suffering with opioid use disorder. Now, anyone who can prescribe opioids, has access to the tools to treat opioid dependence if it progresses to addiction.

Prior to this momentous and long-awaited breakthrough, the former X-waiver requirement was a significant obstacle to initiating treatment for OUD, both from a psychological and practical perspective. In the recent past, any physician who wanted to treat OUD needed to complete an 8 hour training course, receive a certificate of completion, then go to the Samhsa website3 to apply for a buprenorphine X-waiver before proceeding. This created the perception that to be qualified to treat addiction, one had to have more training than was required to prescribe opioids for acute and chronic pain. Because of this, many prescribers were more comfortable writing opioid prescriptions, despite the risk of potential opioid dependence, than they were with the idea of treating opioid addiction. Others felt frustrated by their perceived inability to treat or to find suitable resources and therapies for patients with OUD. This was an untenable situation. Many in the addiction treatment community understood this and advocated for the elimination of the X-waiver requirement so that all medical providers with a DEA number could legally prescribe medications to treat opioid use disorder. I am one of those who advocated and I’m happy to tell you that from my experience I know you can too!

Over the last eight years, I have been treating addictions within my family practice at Citizens Memorial Healthcare, where in 2018, I cofounded our now full-scale outpatient addiction treatment program.4 This experience taught me that treating OUD is nothing to be afraid of.

The main difficulty I faced in managing patients with opioid dependence and addiction was the lack of regional access to opioid replacement therapy, which existed, especially in rural communities, prior to December 2022.

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MISSOURI FAMILY PHYSICIAN October - December 2023

Now, treatment of opioid use disorder has been enshrined as part of the normal continuing education process for Physicians and is being integrated into medical school and residency training programs.

In short, if you can prescribe opioids including buprenorphine for pain you are now qualified to prescribe buprenorphine for opioid dependence, as long as you receive appropriate CME5 as part of the new DEA registration requirement.6 It is important to note that this does not apply to methadone which requires daily dispensing through a certified opioid treatment program. This is an interesting somewhat paradoxical fact, given that physicians may freely prescribe methadone for the purpose of treating chronic pain. However, when using Methadone7, whether for treating opioid use disorder or chronic pain, one should proceed with caution. Methadone has a long half-life, which means that if the dose is titrated up too quickly, the effects become compounding and before you know it the high risk side effects of QT prolongation and respiratory suppression may catch up to the patient. This is why methadone is treated differently than buprenorphine.

This may be new information for some, but for others who have already risen to the challenge of meeting the opioid abuse crisis head on, this may be somewhat familiar. For me, the call came in 2014, a year after I graduated residency and moved from Bronx, NY to Bolivar, MO to start a family practice with a focus in geriatrics. This was prior to the Netflix original series, Ozark8, and in my naivety I did not expect that in a rural Southwest Missouri community, I would be faced with a preponderance of patients who are suffering with addictions to illicit and prescription drugs. However, that is exactly what happened. I soon realized that I did not have the tools nor the local resources to treat these patients for their substance use disorders.

Fortuitously, it wasn’t long before I was introduced to the idea of using naltrexone9, particularly the once monthly depot formulation, for treating alcohol and opioid use disorder. This was a fairly easy and

low risk way for me to start and did not require me to have a DATA 2000 X-waiver. So, I did my own research, consulted some mentors in the field, then started treating a couple of patients with alcohol and opioid use disorder. Over the next few years, this number gradually progressed to five, then 10, then 15 patients. This was without advertising and simply meeting the needs of my patients. Eventually, through word of mouth, I started receiving some referrals from local physicians. I quickly realized that there was a need for a substance abuse program within my hospital system and began to have roundtable planning sessions with our institution’s behavioral health department and hospital administration. Thanks to the help of my wife, who has a background in healthcare and a degree in business, we developed a proposal and business plan which was approved for launch in 2018. My wife was charged with the duty of bringing in grant dollars to support and grow the program and that is what she did, very successfully, to the point that she became the founder and director of our hospital’s new Grants Management Department.

Around the same time, I received my buprenorphine waiver and became board certified in Addiction Medicine10 through the practice pathway.11 This experience has been not without its ups and downs, but all along has been very exciting and rewarding.

A couple of years ago, I was privileged to co-found the new Addiction Medicine Section12 for Christian Medical & Dental Associations (CMDA)13 which provides resources, workshops, and networking opportunities for providers interested in getting involved14 or improving their practice in addiction recovery. I’ve also been privileged to have multiple opportunities to lecture and write on the topic of treating opioid use disorder through CMDA, AAFP, MAFP, and MSACOFP, all the while continuing a busy practice in Family Medicine and geriatrics. Through our addiction program at CMH, we treat opioid use disorder, alcohol use disorder, stimulant use disorder, marijuana dependency, nicotine dependency, gambling, sexual addictions, and others. We are always excited to learn new ways to treat addictions.

If you are new to the idea of integrating addiction recovery treatment into your medical practice, I would like to encourage you to seek more education15 on the subject, find a mentor16, and start with one patient. It is really not as hard as you may think and can be easily integrated into your workflow. An easy way to start is with oral Naltrexone, which is a mu receptor antagonist that blocks the effects of exogenous opioids, as well as endogenous opioids (Beta endorphins)17, released when patients drink alcohol.

Oral naltrexone can be used daily to prevent cravings and block the reinforcing effects of opioids and alcohol in someone who has recently detoxed, however it does require them to be compliant with taking the medication everyday. Oral naltrexone can also be used for the intermittent alcohol binge drinker, employing the Sinclair Method.18 This unique method uses Pavlov’s Law19 of behavioral modification through Classical Conditioning20 (or deconditioning) in which cravings and impulsive use are extinguished by having the patient take oral naltrexone one to two hours before planned or potential alcohol intake. This technique requires the patient to experience the decreased euphoria or other reinforcing effects of alcohol ingestion that occur when the activity of beta endorphin release is blocked by naltrexone at the mu receptor level. Naltrexone is excellent for patients who use both opioids and alcohol on an intermittent basis, or for those who have detoxed and gone through some level of rehab and recovery. Again, compliance is an issue with the oral form of this drug. However, depot naltrexone, which is administered as an intramuscular dose once monthly can be very effective in certain patients and eliminates the need for daily compliance.

This medication can be purchased wholesale and stored at your clinic for dispensing via the buy-and-bill model or can be prescribed through the pharmacy and delivered monthly to your office for administration at next patient visit. If prescribed,

rather than dispensed, it is best if you use a specialty pharmacy that helps with the prior authorization process and enrolls patients in the depo naltrexone patient assistance program21, as this medication is expensive and costs over $1,000 a month. The good news is that it is covered on Medicaid and Medicare, as well as most commercial insurance programs.

Other non-controlled medications that can be used off-label22 for alcohol cravings are baclofen, ondansetron, and topiramate, using the Sinclair method. It is important to make sure that patients with alcoholism receive thiamine and folate supplementation.

L-methylfolate23 is preferred, especially if patients have known MTHFR mutation24 which decreases their ability to absorb folic acid. Providing omega-3 fatty acids can help improve brain function and decision making in these patients. Baclofen and topiramate have also been shown to be beneficial in decreasing cravings for methamphetamines and other stimulants. Especially when used in

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combination with naltrexone, topiramate, baclofen, or bupropion has been shown to also be effective at reducing cravings and drug seeking behaviors in patients with stimulant use disorder.

As discussed above, if you are a prescriber of opioids or other controlled substances, there is no longer a significant barrier to initiating opioid antagonist or replacement therapy for patients suffering from opioid use disorder. If you have reservations about getting started, there are great OUD treatment guides which are now available, such as the AAFP’s practice manual, Treating OUD as a Chronic Condition,25 ASAM’s pocket guide: National Practice Guideline,26 and SAMHSA’s Buprenorphine Quick Start Guide.27 When performing a buprenorphine induction, the key is to make sure that these patients are in moderate opioid withdrawal (COWS scale 13-24) or have completely detoxed from this drug prior to receiving their induction dose of 2 to 4 mg administered in the office. This can easily be achieved with 12 to 24 hours of opioid avoidance.

It is important to monitor patients for 60 to 90 minutes if they have recently used opioids, to observe for precipitated opioid withdrawal.28 If opioid withdrawal occurs, it can easily be treated with an additional dose of 2 to 4 mg of buprenorphine and/or a dose of Clonidine 0.1 to 0.2 mg. Muscle relaxers, nonsteroidal anti-inflammatories, and antiemetics can help treat associated symptoms.

It is reassuring to know that opioid withdrawal, although very uncomfortable for the patient, is not life-threatening. After induction, you can send a prescription to the pharmacy for as many doses of buprenorphine as you feel comfortable providing, but typically a 1 to 3 day supply is given with instructions to titrate up to the lowest effective dose, often between 8 and 16 mg per day. After subsequent visits, dose can be titrated up to soft cap of 24 mg and hard cap of 32 mg per day. Doses above that have been known to be 12

MISSOURI FAMILY PHYSICIAN October - December 2023

prescribed for patients who were formally dependent on high dose fentanyl or methadone, but this is rare.

One of the things that makes buprenorphine so remarkable is that the chances of life threatening overdose are extremely low, as long as the patient is not mixing the drug with high doses of alcohol and/ or benzos. Patients may be continued on buprenorphine for as long as it is proving to be effective and is the implementation of arbitrary tapers or medication withdrawal dates is strongly discouraged, since it can needlessly put patient at risk of relapse and even overdose death, since their opioid tolerance decreases after months of being in treatment. Instead, physicians should engage patients in the recovery process and help them develop goals and strategies for remaining sober, while encouraging them to use all the tools at their disposal to do so.

Important tips for operating a well-rounded and effective

addiction recovery program are, to obtain initial labs, to include a CMP, HIV test, Hep B and C antibodies, and pregnancy test for women. All visits should be subject to either routine or random urine drug screens with the option to send out for confirmation if results are questionable. Alcohol screens should also be done when appropriate. Point of care tests are very helpful, so rapid results can be reviewed during visits. Engaging the collaboration of local behavioral health specialists and social/case workers can be a great asset to your program and it is important to encourage patients to join a substance recovery support group or elicit the services of a peer recovery specialist. Sober living homes may be appropriate for certain patients who need more accountability or are trying to get away from bad influences or an unsafe living environment.

It is important to recognize and treat addiction as a chronic disease which requires long-term follow-up and continuity of care. When my wife and I were developing our addiction recovery program, we drew up this flow-chart to demonstrate our vision for how this should work. We now have one RN Case Manager, one rooming nurse, one peer support specialist, one LPC therapist, and two nurse practitioners. We serve one main and three satellite clinic locations. I serve as medical director, am on site in our main office two days a week, and continue to maintain a busy Family and Nursing Home Practice.

I feel blessed every day to be able to serve my patient’s medical and behavioral needs, using a diverse tool kit and a multimodal approach. I strongly encourage you to take advantage of this unprecedented opportunity to treat opioid use disorder and other addictions at a time in history that the need is greater than it ever has before. If you do, I am sure you will find it rewarding and will discover that there are others around you, like myself, who will be there to provide mentorship and support along the way.

Additional Opioid Dependence Tools and Resources:

https://alosahealth.org/wp-content/uploads/2023/03/UnAd_ IntroOUD_2.23_PACE-DOH.pdf https://alosahealth.org/wp-content/uploads/2023/02/Tearoff_ AcutePain_2.23_PA-DOH.pdf https://onlinelibrary.wiley.com/doi/10.5694/mja2.52002 References on pages 44-45.

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MISSOURI FAMILY PHYSICIAN October - December 2023

MO-AFP.ORG 15

Management of Tendinopathy

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endinopathy is defined as persistent tendon pain and associated loss of function related to mechanical loading.1 The pain can become chronic, leading to reduced activity tolerance affecting an individual’s capacity to be active or perform their Christian Verry, MD, CAQSM professional obligations. It Faculty, Mercy Family Medicine affects individuals of varying Residency, St. Louis, MO ages and results in differing Team Physician, St. Louis Cardinals, degrees of pain and loss of and Lindenwood University function. Recovery is similarly variable, with some tendons recovering with minimal intervention while others remain resistant to treatment. This article will review the pathology contributing to tendinopathy, discuss how it may fit into a fluid model of progression and regression, and discuss management options for some of the most common types of tendinopathy seen in primary care clinics.

The pathology of tendinopathy is poorly understood. Longitudinal monitoring of histopathologic changes in humans is ethically challenging. Load (volume, frequency, and intensity of stress) appears to play a key role in the development of tendinopathy2, although the amount of load that is required to induce pathology is not clear. Additionally, an individual’s ability to tolerate load is affected by intrinsic factors such as age, sex, biomechanics, and body composition. One model describes a continuum of pathology with three stages: reactive tendinopathy, tendon disrepair (failed healing), and degenerative tendinopathy (Figure 1)2. Adding or removing load is the primary stimulus that moves the tendon forward or backward along this continuum. Key characteristics of each stage of tendinopathy in this model can be found summarized in Table 1.

In reactive tendinopathy, an acute tensile or compressive load stimulates a non-inflammatory proliferative response in the tendon matrix, causing an adaptive thickening (increased cross-sectional area) in a portion of the tendon. This differs from normal tendon adaption to tensile load, which occurs through tendon stiffening, not increased thickness. This reactive response is a short-term adaptation to overload. The tendon has the potential to revert to normal if the load is reduced or sufficient time is allowed for

Table 1

16

Stage of Tendinopathy

Patient Characteristics

Pain reports

Exam

Imaging

Histopathology

Reactive

Younger, active, sudden increase in loading activities or direct blow to tendon

Pain with higher loading activities

Focal tendon swelling or increased focal thickness

Fusiform swelling.

Increased diameter on US and MRI. No increased signal on MRI

Collagen structure is maintained, no neovascularization

Disrepair

Chronically overloaded tendons in young; Older patients with lower loads

Pain with lower intensity loading activities

Thickened tendon, with localized changes in one area

US with focal areas of hypoechogenicity, discontinuity of collagen fascicles, vascularity on color Doppler

Increased proteoglycans collagen separation and disorganization of matrix

Degenerative tendinopathy

Usually older (middle aged), but can be young active with chronically overloaded tendon

Repeated bouts of pain that resolve, then return when load changes

Focal nodular areas, +/- general thickening

US with minimal collagen fascicles, large hypoechoic regions, large neovascularization.

MRI with increased tendon size and signal

Cellular apoptosis, acellularity, little collagen.

MISSOURI FAMILY PHYSICIAN October - December 2023

Stage of Tendinopathy

Pharmacologic management

Physical management

Reactive/Early tendon disrepair

Tenocyte and aggrecan inhibitors (NSAIDS Ibuprofen) X 2 wks

Load management: reduction in frequency, intensity, and/or volume of tendon load

Late tendon disrepair/Degenerative

Prolotherapy, Sclerosing therapy, Gylceryl trinitrate

Eccentric loading, ESWT, friction

Table 2 recovery. Clinically, this form of tendinopathy is more likely to be seen in young athletes. One example is a jumping athlete who dramatically increases their number of jumping/landing repetitions per week then experiences patellar tendon swelling and pain. The next stage of tendinopathy, tendon disrepair, is like reactive tendinopathy, whereby the tendon attempts to heal, but there is more extensive matrix breakdown in this stage. An increased number of chondrocytic cells with increased production of proteoglycans act to disrupt the collagen fibrils and cause disorganization of the tendon matrix. Increased vascularity and neuronal ingrowth may occur, both potentially contributing to pain.

Ultrasound will show disorganized collagen fibrils and focal areas of hypoechogenicity, and color Doppler may show neovascularity. MRI will show a thickened tendon with increased signal. Clinically, tendon disrepair is seen across age spectrums and usually in situations where symptoms have been present for a longer time period (months-years).

Older individuals may develop this stage of tendinopathy with lower loads.

Some reversibility is possible with load management and appropriate exercises to stimulate matrix development. The third stage, degenerative tendinopathy, occurs due to apoptosis and tenocyte exhaustion. Large areas of the matrix are disordered and filled with vessels and matrix breakdown products. Little collagen is seen throughout the tendon.

Ultrasound will show significant areas of hypoechogenicity and large vessels on Doppler. This stage is more common in older individuals but may also be seen in younger athletes with chronically overloaded tendons. Individuals may report repeated episodes of pain that resolve only to return when the load changes. There is little capacity for reversibility at this stage, and these tendons are at risk for rupture with higher loads.

The pain associated with tendinopathy can occur at any stage and is not associated with the level of pathology. Pain may occur with normal-appearing tendons on imaging, while two-thirds of degenerative tendons at risk for rupture may be pain-free2. The etiology of the pain is poorly understood but may be due to neovascular ingrowth or from biochemical substances (catecholamines, acetylcholine, glutamate) acting on sensitized nerves. Pain is the single clinical factor the clinician looks to change, and a decreased painful response to load is an indicator of treatment success.

Broadly speaking, management of tendinopathy can be based on the presumed stage of the disease. For reactive tendinopathy or the early stage of disrepair, reducing load alone may be sufficient.

As this stage is predominantly proliferative with increased cellular activity, the focus should be on decreasing stimulation to the tendon. Assessing and modifying the intensity, duration, frequency, or type of load is the key clinical intervention. Simply allowing adequate recovery time between periods of high tendon load may be sufficient. Studies show that tendon response peaks around three days following a bout of intense exercise2. Using this as a reference to appropriately space high-load activities may result in improved symptoms. Activities that produce tendon load without energy storage and release (i.e., cycling or weight training) can often be maintained as they are less likely to stimulate tendon response.

High-impact activities (jumping, plyometrics) should be avoided.

Short-term (2 weeks) use of non-steroidal anti-inflammatories (NSAIDs) may be considered in reactive tendinopathy, as they have been shown to inhibit expression of ground substance proteins (aggrecan) responsible for tendon swelling. Ibuprofen may be the preferred NSAID, as it has not been shown to inhibit ultimate tendon repair2.

For late tendon disrepair or degenerative tendinopathy where there is apoptosis and tenocyte exhaustion, the focus should be on treatments that stimulate cell activity, increase protein production (collagen and ground substance), and restructure the matrix.

Eccentric exercise is one of the most reliable treatment modalities for this stage, with most individuals receiving benefits within 4-6 weeks of initiation.2 It has been shown to increase collagen production in abnormal tendons, improve tendon structure in both the short and long term, and decrease neovascularity.

One meta-analysis found eccentric exercise to be beneficial for pain, function, and return to activity.2 Other treatment modalities for this level of tendinopathy include friction therapy and ultrasound, although neither has been shown to be superior to eccentric loading. There is inconsistent data for extracorporeal shock wave therapy (ESWT) and glyceryl trinitrate patches. The injection of substances into or around the tendon to stimulate a healing response may also be appropriate for this stage. Prolotherapy, whereby the clinician injects dextrose or blood products into or around the diseased tendon, has been shown to

Pain is the single clinical factor the clinician looks to change

MO-AFP.ORG 17

decrease neovascularity and reduce tendon diameter. Similarly, the use of sclerosing agents (polidocinol) has been shown to improve pain and structural outcomes in Achilles and patellar tendons versus placebo2. Finally, surgery is a reasonable option for those individuals who have failed more conservative treatments, although existing data do not show it to be superior to eccentric loading programs for patellar tendinopathy. Surgical outcomes appear to be superior for active versus sedentary individuals2.

Eccentric loading programs for specific tendinopathy are well established in the literature. The Alfredson model involves the individual performing a painful eccentric contraction of the involved tendon, for three sets of 15 repetitions each, two times per day, seven days per week, for 12 weeks. The pain should be moderate (as determined by the patient), and the individual can wear a weighted backpack if there is no pain with unweighted loading. Patients showing improvement at six weeks may be released to some prior activities, with a slow progression to full activities as symptoms allow. The patellar tendon (Jumper’s knee) and the Achilles tendon (mid-portion tendinopathy) have both shown consistently good outcomes with this approach.3,4 For Jumper’s knee, the individual should stand on a 25 degree decline board, toes pointed downward, trunk upright. They should transfer all their weight to the affected limb and slowly flex their knee to 70 degrees (Figure 2).

Figure 2 To return to the starting position, Figure 2: Starting and ending they use their nonpositions for eccentric loading of affected limb and/ the patellar tendon. P Jonsson, H or hands such that Alfredson. Superior results with the affected limb is eccentric compared to concentric minimally engaged in concentric quadriceps training in patients activity. In a with jumper’s knee: a prospective study comparing randomized study. British Journal eccentric to Sports Medicine 2005;39:847–850. concentric loading for Jumper’s knee 9/10 tendons patients were satisfied with treatment, with significantly improved visual analogue scales (VAS) and Victorian Institute of Sport Assessment scores (VISA; a functional score, validated for patellar tendinopathy). In Figure 3 the concentric Figure 3: Starting (A) and ending group 9/9 tendons patients were (B) positions for eccentric Achilles not satisfied, loading 18

MISSOURI FAMILY PHYSICIAN October - December 2023

Figure 1 and there were no statistically significant changes in VAS or VISA scores. At follow-up (32.6 months) patients in the eccentric group remained satisfied and had returned to physical activity, while all the individuals in the concentric group were unsatisfied and had been treated with either surgery or sclerosing agents.3 For midportion Achilles tendinopathy (pain 2-6 cm above the insertion), the patient should use their unaffected limb and/or arms to achieve a fully plantarflexed position at the ankle, transfer their weight to the affected limb, then slowly lower the affected ankle to a fully dorsiflexed position (figure 3). Data show this protocol is successful in approximately 90% of those with mid-tendon pain and pathology.4 A follow-up study (3.8 years) on patients with mid-substance Achilles tendinopathy treated with eccentric loading found 22 of 25 patients were satisfied with treatment and active in Achilles loading activities at their desired level. Ultrasound examination found that tendon thickness had decreased significantly (p<0.005) for the treated individuals (7.6 (2.3) v 8.8 (3)mm; mean (SD)).5 This approach is not as successful for insertional tendinopathy.

In summary, tendinopathy is a poorly understood process that may result in chronic pain inhibiting optimum function. Load plays a critical role in the development of tendinopathy, and intrinsic factors may place certain individuals at increased risk. The model discussed here helps to categorize diseased tendons and to structure management plans based upon the stage of involvement. Critical to this is the understanding that tendinopathy exists on a continuum and that an individual can move between stages by modifying load. Management can be determined by the most likely stage of tendinopathy, with load modification defining early-stage treatment and eccentric loading forming the cornerstone of mid and latestage treatment. Accurate staging of the disease with a thorough history and appropriate imaging, followed by a targeted treatment approach, can help many patients find relief from the activitylimiting pain associated with tendinopathy.

References on pages 44-45.

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MO-AFP.ORG 19

Case Study: OMT Low Back Pain

L

Rachel Sachs DO, CAQ SM University Health, Kansas City Kansas City, MO

Wesley Goodrich DO, MPH, PGY3 University of Missouri Kansas City Family Medicine Residency Kansas City, MO 20

ow back pain is a common health problem and is among the leading causes for activity limitation, disability, and work absenteeism. The mainstay of treatment for chronic low back pain is multifactorial.

Osteopathic medicine’s tenets address the complex interrelatedness of the body, mind, and spirit, giving recognition to its structural, functional, and self-healing capabilities.

Furthermore, osteopathy can play a vital role in more accurately identifying the etiology of chronic low back pain and should be employed to help treat this condition.

Patient is a 62-year-old female, with past medical history (PMH) pertinent for levoscoliosis of lumbar spine, who presented to clinic with complaint of chronic low back pain rated as an 8/10. Osteopathic exam pertinent for dysfunction in sacroiliac joint in addition to compensation at innominate and lumbar regions. PT noted significant improvement of pain after single (?) osteopathic manipulative therapy (OMT) treatment down to a 2/10.

Osteopathic exam noted dysfunction in multiple regions likely contributing to pain and

MISSOURI FAMILY PHYSICIAN October - December 2023

dysfunction. After treatment with OMT, patient noted subjective improvement of pain as well as objective findings including improved posture and range of motion. Osteopathic treatment is an ex-tool which should be included in management for chronic low back pain.

Patient is a 62-year-old female with PMH pertinent for levoscoliosis of lumbar spine, who presents to clinic today with complaint of chronic low back pain rated as an 8/10. PT noted pain radiated down both lower extremities with associated numbness and tingling. Pain is worse with forward flexion with associated weakness of legs.

She has been seen previously by pain management, a primary care provider, and an orthopedic surgeon. She has tried various NSAIDs, muscle relaxers, and narcotics without relief of symptoms. She had epidural steroid injection, which only provided about two weeks of relief of symptoms. She notes pain gets in the way of her job, walking her dog, and activities of daily living.

Previous work-up included lumbar x-ray and MRI without contrast notable for grade 2

spondylosis at L4-L5 with anterolisthesis, diffuse facet arthrosis, concentric disc bulge at L4/L5 and severe spinal stenosis.

On exam, patient had normal vital signs. Pt standing with forward flexion and truncal rotation to the left. She is tender to palpationat lumbar paraspinal and sacroiliac joints (more on the right than the left). Negative straight leg raise, positive slump test. Leg strength 4/5 in right leg compared to left. Osteopathic exam notable for sacral torsion and extension, right anterior innominate, left posterior innominate, and L5 FSRRR (flexed, side bent right, rotated right).

After performing OMT, including muscle energy, balanced ligamentous tension, and counterstrain, patient noted significant improvement of pain down to a 2/10. She was able to stand upright without pain and had less numbness and tingling in her legs.

Chronic low back pain affects up to 23% of the population worldwide.2 The economic burden associated with low back pain in high-income countries from direct and indirect costs was found to be on average over 2.5 billion dollars annually.3 A multitherapy modality including a mixture of pharmacologic and nonpharmacologic interventions are necessary for treating chronic low back pain. Imaging is not recommended for most patients with nonspecific low back pain in the absence of red flags per the Choosing Wisely Campaign and The American College of Radiology Appropriateness Criteria.2 Currently there are a multitude of conservative methods to treat low back including pharmacological, injections, physical medicine and rehab, physical therapy, acupuncture. When these conservative methods fail, patients are often referred to surgery.

Osteopathic medicine offers a unique opportunity to address structure, pain, and function of the low back. Osteopathic tenets address the complex interrelatedness of the body, mind, and spirit, giving recognition to its structural, functional, and self-healing capabilities. A systematic review and meta-analysis of osteopathic manipulative interventions for chronic low back pain, concluded that osteopathic manipulation may have efficacy in pain reduction, improving functional status for patients.4 One randomized control trial including 42 participants demonstrated greater subjective pain reduction among individuals receiving five weeks of treatment with osteopathic manipulation when compared to therapeutic exercises.5

L4-L5: Grade 1 anterolisthesis with uncovering of the disc and concentric disc bulge. Annular fissure. Severe facet arthropathy.

Ligamentum flavum thickening. Moderate to severe spinal canal stenosis. Spinal canal measures approximately 6 mm at midline.

Moderate to severe bilateral neural foraminal narrowing.

L5-S1: Disc bulge. Mild facet arthropathy. No significant spinal canal stenosis. No significant neuroforaminal narrowing.

Utilizing both osteopathy’s pedagogical approach to evaluating patients and its manipulative techniques to treat chronic low back pain through pain reduction and the promotion of self-healing may offer a superior modality for addressing this complex and prevalent issue. Consider referring to a doctor of osteopathy or utilizing OMT as a non-invasive treatment option for chronic low back pain.

References on pages 44-45.

The image on the right is a model representation of a backwards sacral torsion with associated L5 dysfunction.

The images above depicts the positioning and direction of force [white arrow – physician; black arrow – patient] in MET of sacral torsion [1] MO-AFP.ORG 21

Case Study: An Osteopathic Approach to Temporomandibular Joint Pain

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emporomandibular joint dysfunction (TMJ) is a common condition seen in the primary care setting.

Osteopathic manipulation is a useful modality when evaluating treatment options for the management of TMJ Elizabeth Verna, DO disorders.

Faculty, Mercy Family Medicine A 29-year old primigravid patient at 23 weeks Residency, St. Louis, MO gestation presented to a family medicine clinic for her routine prenatal care. We diagnosed temporomandibular joint dysfunction and somatic dysfunction of the occiput, cervical neck, and muscles of mastication. We successfully treated the patient using osteopathic manipulation.

Temporomandibular joint dysfunction can affect up to 31% of the population. Conservative treatment is effective for many patients and can include a range of pharmacologic options as well as manual therapies. Patients may benefit from osteopathic manipulation with myofascial release, counterstrain, or muscle energy techniques. Treatment should include evaluation of the head and neck as well as jaw.

The patient noted increasing pain over bilateral temporomandibular region which were also causing severe headaches and making eating difficult. She had a history of temporomandibular joint pain in the past and prior to pregnancy utilized ibuprofen to control the pain. She was prescribed acetaminophen 1000mg three times daily, cyclobenzaprine 5mg twice daily, and magnesium 400mg at bedtime. Her pain persisted despite these measures, and she returned two weeks later for osteopathic manipulative treatment.

On exam, she was noted to have somatic dysfunction of the cervical region as well as restricted range of motion on opening the mouth, translation of the jaw to the right, and popping palpable over the right temporomandibular joint. The surrounding tissue was also palpably hypertonic.

Osteopathic manipulation was performed with passive and active techniques. Myofascial release to the cervical spine and pterygoid muscles were performed as well as muscle energy to the cervical spine and temporomandibular joint and counterstrain of the right masseter. Suboccipital release was also performed.

She returned for two more sessions of osteopathic manipulation over the course of her second trimester. The rest of her pregnancy 22

MISSOURI FAMILY PHYSICIAN October - December 2023

was uneventful, and pain was controlled thereafter with acetaminophen alone.

Temporomandibular joint dysfunction is a commonly encountered problem in the primary care setting with an overall prevalence of 31% in adults and 11% in children.9 It is characterized by pain in the jaw, around the temporomandibular joints, pain around and/or in the ear, aching facial pain, difficulty chewing, or decreased motion of the mouth.3 The temporo-mandibular joint is made up of the condyle of the mandible with the mandibular fossa and the articular tubercle of the temporal bone. The muscles of mastication allow for movement of the joint and are comprised of the temporalis, masseter, medial pterygoid and lateral pterygoid. The movements seen through the temporomandibular joint include opening and closing of the mouth as well as side to side movement of the mandible and protraction/retraction of the mandible.1 Many patients will improve with conservative therapy alone.

Treatment options for conservative management includes physical therapy, behavior modification, and occlusive splints. Medications such as NSAIDs, muscle relaxers, systemic steroids, benzodiazepines and tricyclic antidepressants may also be beneficial.3 Dysfunction of the joint may be related to somatic dysfunction of the muscles of mastication, the sternocleidomastoid or cervical spine, and special attention should be paid to these areas.2 Current literature supports osteopathic manipulative treatment as an appropriate measure in conservative management and can help with decreasing pain, increasing range of motion and normalizing jaw function.1,7 For clinicians who incorporate OMT into practice, consideration can be given to counterstrain and muscle energy techniques aimed at the muscles of mastication. These techniques may include intraoral myofascial release for some of the deeper muscles, such as the pterygoids. Consideration of the cervical spine and OA may include muscle energy, counterstrain or high velocity low amplitude thrusts. Suboccipital release and cranial techniques can also be performed.7 Conservative therapy is an appropriate first line in most patients presenting with temporomandibular joint dysfunction, which includes medications and manual therapies such as physical therapy or osteopathic manipulative therapy. Physicians utilizing osteopathic manipulative therapy should evaluate for somatic dysfunctions in the cervical spine, cranial fields, muscles of mastication and sternocleidomastoid in order to ascertain the most appropriate manipulations to perform.

References on pages 44-45.

ADVOCACY DAY FEBRUARY 26 - 27, 2024

JOIN US AT THE COURTYARD MARRIOTT & THE MISSOURI STATE CAPITOL, JEFFERSON CITY, MO MONDAY, FEBRUARY 26

2:00-3:00 pm – Private tour of the Capitol Whispering Gallery.

6:00 – 8:30 p.m. – Legislative Briefing and Dinner Buffet at Courtyard Marriott (In-person/Virtual Legislative Briefing)

TUESDAY, FEBRUARY 27

8:00 – 9:00 am – Breakfast Buffet at Courtyard Marriott 9:00 am – 1:00 pm – Legislator Appointments 11:30 am – 1:00 pm – Luncheon Buffet at Courtyard Marriott 1:00 – 4:00 pm – MAFP Board of Directors Meeting (In-person/Virtual)

REGISTER ONLINE: WWW.MO-AFP.ORG/ADVOCACY/ADVOCACY-DAY/ We encourage you to invite a colleague, medical student, or resident to join you to promote the importance of family medicine and primary care. This is your opportunity to educate your State Senator and State Representative on issues that affect you, your profession, and your patients.

Make your lodging reservation at the Courtyard Marriott, 610 Bolivar Street, Jefferson City, MO 65101, (573) 761-1400. Be sure to reference the Missouri Academy of Family Physicians to receive the discounted rate of $134 per night. The last day to make a reservation in our block is January 26, 2024. Any reservations made after that date are subject to availability.

Limited complimentary lodging is available with preference to residents and students.

To request a complimentary room, email Kathy Pabst at kpabst@mo-afp.org.

Questions? Contact MAFP by calling (573) 635-0830 or emailing office@mo-afp.org.

YOU ARE THE VOICE OF MISSOURI FAMILY PHYSICIANS! MO-AFP.ORG 23

Reflections from the 2023 Summer Externs

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he Family Health Foundation of Missouri (FHFM) and the American Academy of Family Physicians Foundation sponsored six medical students to participate in the 2023 MAFP Summer Externship Program. Because of your financial support, we can continue this program for medical students interested in family medicine each year. Learn more about the FHFM by visiting https://www.mo-afp.org/foundation/.

If you are a student interested in participating in the program, visit https://www.mo-afp.org/join/residents-students/externships/ for more information. Below are the stories about each of the externs’ experiences this summer. As you read each reflection, there is a common theme, continuity in care for your patients and full-scope family medicine. The medical students selected to participate in this year’s externship program are just a small example of the future family physicians in Missouri.

Abby Crede, MS3

University of Missouri Kansas City Site: University of Missouri Columbia Family Medicine Residency This summer, I was selected to be an extern for the University of Missouri Columbia Family Medicine Residency Program. I applied for this position as I learned early in my training that I had a passion for meaningful physician-patient relationships. I hope to be a provider with a broad education equipped to treat anything that walked through the clinic or hospital doors and found these expectations perfectly aligned with family medicine!

Through this program, I worked with many family medicine attendings and residents at Mizzou in both the inpatient and outpatient settings. This was an incredibly valuable experience for 24

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me as I completed it just months before I began working on my residency application for the specialty of family medicine. I was so grateful to complete my externship here, as it gave me great insight into what medicine can look like in hospitals different from my home institution at UMKC. At Mizzou, the residents allowed me to hit the ground running from the very first day and treated me like a valued member of the team. On the inpatient team, we stayed very busy and learned all day. We saw a wide variety of patients who were extremely well taken care of by the residents and attending physicians on the team. No concern was left unheard, and patients were discharged home with great plans to follow up again with the family medicine teams at Mizzou. This team truly spoke to the continuity that is family medicine, as the patients were treated by these teams both in and out of the hospital.

I was also privileged to get to work in outpatient clinics during my time at Mizzou. I was able to experience a clinic near the main hospital as well as a more rural clinic and learn how the patient populations and common concerns varied at each. The days were busy, but the hours passed quickly as we jumped from room to room, treating children with twisted ankles and taking biopsies from persistent rashes.

I will forever be grateful for the month of education and experience the attendings and residents at Mizzou gave me.

Each one was knowledgeable and caring, making each day fun and exciting. I learned so much more about the field and was given even more insight into what life is like as a family medicine resident. I am also forever grateful to the Missouri Academy for hosting a program that allows students to explore such a wonderful specialty.

I felt extremely confident leaving this experience that family medicine will always be my home.

Tiffany Braun, MS1

Kansas City University Site: Bothwell-University of Missouri Rural Family Medicine Residency Over the summer, I was honored to participate in the MAFP Summer Externship Program with the University of Missouri—Bothwell in Sedalia, Cole Camp, and Lincoln. I was paired with physicians and shadowed them during morning hospital rounds, clinic hours, and OB service.

Over the four weeks I was there, I experienced rural family medicine to the fullest. My favorite day was watching a c-section in the morning and ending the day with nursing home rounds. I saw many patients who were related and multiple generations of one family. I witnessed the importance of knowing what resources are available to patients and where the resources are located in order to help the overall well-being of the patient.

During my last week, I had the opportunity to experience the continuity of care and saw a patient who had a follow-up from the first week I was there. Through this externship, I was able to experience the beauty of family medicine. While I had always been interested in family medicine, this summer instilled in me a passion for continuity of care. Experiencing the joys of seeing a baby in one room followed by an elderly patient in the next is something I will always remember.

Another aspect of family medicine I enjoy is patient education and watching patients better understand their health. I am thankful for the welcoming atmosphere and the time the physicians spent teaching me and answering questions to further my education. Throughout the summer, some of the physicians asked questions and challenged me to expand my understanding by reporting back the answers to the questions I didn’t know. I value everything I have learned and the advice I received. I am appreciative of this opportunity to spend my summer learning more about family medicine and for the financial support from the Family Health Foundation of Missouri.

Aleiyah Dapog, MS1

Saint Louis University Site: Saint Louis University Family Medicine Residency I am so grateful for the opportunity the MAFP gave me to join SLU’s Family Medicine Residency team at St. Mary’s Hospital and the Family Care Health Center in Carondelet.

While I already had an interest in family medicine previously, I left the program with not only a greater interest in the field, but also a profound appreciation for the comprehensive, patient-centered medical and behavioral health care that comprises primary care.

Throughout this experience, I was able to expand my script on illness topics I had already learned in school, like hypertension and heart failure, even giving a short presentation on guideline-directed medical therapy for patients with HFrEF. I saw just how much I had 25

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learned in my first year of medical school but also realized how much more there is to learn.

For instance, I encountered topics I had not previously learned, like Prader-Willi, community-acquired pneumonia, and even xylazine toxicity. Through didactics and teaching done by physicians I worked with, I also learned about topics such as buprenorphine macro dosing, steroid injections, and how to do various types of ultrasound.

Besides this, something I really enjoyed about this program is that I gained confidence and comfortability with taking a history and conducting a physical exam. Before this experience, I had only worked with standardized patients, so I was excited to utilize these skills in real clinical practice. From child wellness visits to prenatal visits to hypertension follow-ups, I got to practice these skills with patients of all ages with a wide variety of conditions.

The residents provided great feedback and advice so I could continue to improve in my patient encounters. They even talked me through how to come up with an assessment and plan, which I had not done in the past. They also walked me through some common procedures done in the clinic, like Nexplanon insertions/removals and steroid injections. All of this clinical experience I gained was enhanced by the investment everyone was willing to make in my medical education.

Whether we were working with pediatrics, women’s health, geriatrics, or other areas, there was one theme that showed me how rewarding family medicine can be–getting to celebrate with your patients and form longitudinal relationships with them. Seeing the smile on a patient’s face when they finally met their A1C goal or observing how excited a first-time pregnant patient is to see their very first ultrasound or hear their baby’s heartbeat for the first time are the types of experiences that showed me what there is to love about this field. Having these moments of celebration is something I want to continue experiencing in my future career as a physician.

After a year of being mainly in a classroom, this experience brought the spark back in my medical journey. Everyone in SLU’s Family Medicine department was very welcoming to me, and I am excited to get to work with them again next year when I start clerkships. Overall, I’m so grateful for this experience and excited to continue my journey to becoming a physician!

James Liu, OMS3

ATSU Kirksville College of Osteopathic Medicine Site: Mercy Family Medicine Residency The MAFP Summer Externship gave me an even greater appreciation for family medicine. This four-week hands-on experience allowed me the opportunity to refine my medical skills. This experience opened my eyes to the diverse array of opportunities available in family medicine, including pediatrics, geriatrics, sports medicine, OMT, procedures, mobile medicine, street clinic, and more. Being in the clinic every day was a great reminder of why I entered medicine. The opportunity to practice medicine while also being able to make valuable, meaningful, longterm relationships with patients and their families is what makes this specialty one of a kind.

The individuals that I have had the privilege to meet this summer have been a constant source of inspiration for me. Their dedication MO-AFP.ORG 25

to mentorship, teaching, and serving the underserved resonates deeply with me, and I look forward to continuing this mission throughout my career.

I am grateful to MAFP, AAFP, and FHFM for this invaluable opportunity. I want to give a special thank you to Dr. Sarah Cole and the entire Mercy Family Medicine Residency program in St. Louis, MO, for welcoming me with open arms and taking the time to teach and expand upon my medical knowledge.

Vikita Patel, MS1

Kansas City University Site: Research Family Medicine Residency It was my first day of the summer externship at Research Medical Center and I was headed straight to the inpatient floor. One of the residents came to get me, and we walked over to round with the rest of the team. We saw a whole range of patients that day, but one that stuck out to me was ‘Jane.’ She was here for alcohol toxicity during pregnancy, and it was a full circle moment for me because of the public health work I had done in alcohol and substance abuse, specifically in fetal alcohol spectrum disorders.

Understanding those social factors that led Jane to this point and then working with the team medically managing her care was a surreal experience. I was able to bring together my knowledge of public health and community health and apply it to the practice of family medicine. Seeing the management of Jane from the inpatient setting and then to the OB floor was so meaningful.

Just like Jane, I got to see so many patients in the hospital in some of the worst conditions they have been in their lives to seeing them weeks later in the outpatient clinic, doing so much better than before. Having that continuity of care over the weeks with the patients and seeing them improve was a rewarding feeling and reminded me exactly why I am so interested in family medicine.

That week on the inpatient service, I saw a myriad of conditions, from third-degree burns to psychological crises. The variety was unexpected, but I learned so much.

As someone passionate about women’s health, being on the OB service for a week was an amazing experience. I got to not only see my first delivery but also got to scrub in on multiple c-sections. I worked with some amazing residents who taught me so much. I learned how to scrub in on surgeries, practice suturing on models, read fetal heart monitors, triage patients, and so much more. I saw many of the patients in the OB clinic the week after, and it was a great feeling to see them doing so well with their newborns.

During outpatient clinic, I worked with different attendings and residents throughout the week. I loved seeing how each physician had their method and way of caring for their patients, each unique to their personality and their patient. One resident had a strong interest in obesity management, and I learned so much from listening to him counsel his patients. It was evident that he loved what he was doing and was knowledgeable on the topic, and the patients felt heard and taken care of, too.

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I saw a variety of things in the clinic—from managing chronic conditions to joint injections, punch biopsies, and cast removals.

At the end of the four weeks, I remembered thinking that there was so much I had learned. I knew the most common drug prescribed for nerve pain. Or what screening tests we recommend for 55-year-olds. Or what we ask the parents during a well-child visit. I had an amazing time during my family medicine externship working with Dr. Arabindoo and her team, and it has made me even more excited to pursue family medicine. I feel prepared to tackle my rotations and owe it all to this opportunity!

Yuan Xie, MS1

Kansas City University Site: University of Missouri Kansas City Family Medicine Residency This summer, I had the incredible opportunity to complete an externship at University Health, Lakewood campus. It turned out to be an enriching experience that pushed me out of my comfort zone while providing excellent support in a conducive learning environment.

As soon as I arrived at the hospital, I was warmly greeted by my scheduling coordinator, who had prepared a color-coded schedule and provided me with maps of everything I needed, ensuring I could make the most of my time there. Throughout the program, I had the privilege of attending various lectures and hands-on demonstrations, which broadened my horizons and allowed me to explore different aspects of healthcare.

The majority of my time was spent in the family medicine clinic, where I gained valuable practical experience. However, I also had the opportunity to work in diverse areas, such as the maternal care clinic, labor and delivery, inpatient medicine, and OMT clinic. This exposure provided me with a comprehensive understanding of how rotations function in a real-world medical setting.

One aspect that stood out to me was the camaraderie among the other fourth-year students from UMKC who were part of the program. Sharing the same schedule, we bonded over our shared passion for medicine and learning, exemplifying the dedication of the program organizers to provide the best experience possible for all participants. During my time at University Health Lakewood, I encountered some transportation difficulties due to not having a car. However, the staff went above and beyond to accommodate me, ensuring that I could still make the most of the externship and receive a superb education.

The hands-on experience was truly invaluable. I witnessed and participated in procedures like trigger point injections, cervical exams, and history taking, which enhanced my clinical skills and gave me the confidence to apply my knowledge in real patient scenarios. I am deeply grateful to University Health Lakewood for this opportunity, as it kept me motivated and inspired throughout my second year of studies. I would also like to extend my appreciation to MAFP for organizing this exceptional externship program, which has undoubtedly left a lasting impact on my medical education and career aspirations.

Missouri AFP Participates in National Conference

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he 2023 National Conference of Family Medicine Residents and Medical Students (NCFMRS) was a wonderful event.

This year’s meeting drew more than 4,800 physicians, residents, and students from across the country. Missouri had 86 attendees participate in leadership development. Sessions focused on family medicine, clinical procedures, networking, and celebration on July 27-29 in Kansas City. Attendees celebrated on the last evening of the conference at Midland Theater for a concert by award-winning Kansas City based party band Twice on Sunday during National Conference Celebration.

The expo hall featured 600+ residencies, recruiters, and other valuable exhibitors from across the country. Missouri residencies and recruiters were together on Missouri Street to promote the diverse features of the state. Not only is Missouri Street valuable to the residents and students, it is also an opportunity for family medicine programs to network and collaborate to promote Missouri to our future residents and family physicians. Residency booths were an opportunity for medical students to meet with current residents because so many residents participate in recruitment efforts for their programs.

The Family Health Foundation of Missouri (FHFM) financially supports one resident and one student to attend this important event every year as delegates to represent students and residents across Missouri. Selection of our delegates is based on a rotation cycle. This year’s Missouri representatives were: Resident: Wesley Goodrich, MD, PGY3, University of Missouri – Kansas City Student: Michelle Matthew, MS3, Kansas City University Students and residents are chosen based on a rotation of Missouri programs. Next year’s resident delegate will be from Cox Family Medicine Residency and the student delegate will be from Washington University. Residents and students interested in attending should inquire within their programs.

MAFP student delegate Michelle Mathew, MS3, from KCU, appreciated the opportunity MAFP provided to attend the National Conference. “I am a third-year medical student at Kansas City University, and I am so grateful to share my experience attending the national AAFP conference. As a first-time attendee of this conference, I was nervous about finding my way through and navigating through all the various workshops, congress

meetings, and network opportunities. However, within 30 minutes of being at the conference, I felt more welcomed than I imagined.

In addition to being a student delegate, I also had the excellent opportunity to become part of a reference committee where I was part of a small group that heard testimony of resolutions submitted to the AAFP. As part of this committee, I prepared an initial recommendation for eight out of 30 resolutions submitted. I also had the wonderful chance to collaborate with Dr. Goodrich and Dr. Luchini in writing a resolution to the AAFP. In addition to these great opportunities, I had the privilege of meeting many different residencies nationwide. I gained so much knowledge of all the various programs and resources available. I was inspired by many family physicians, students, and leaders I met at the conference. I am so grateful to have been a student delegate for Missouri and am thankful to have made lifelong colleagues and leadership skills at the national AAFP conference.”

Wesley Goodrich, MD, UMKC, Resident Delegate and MAFP Resident Board Member said, “It was a privilege and honor to be able to serve as the Missouri resident delegate for the National Congress of Delegates at the AAFP National Conference! There is an ineffable sense of agency and empowerment being surrounded by your peers from around the country, who are also looking to further the mission and practice of family medicine in a similar fashion; almost as if destiny placed you all in the same room. The experience left many of us feeling more energized than when we arrived at the conference, coming from busy residency schedules.

Being able to collaborate with peers who are at a similar place in their careers and discussing persistent and emerging issues on the forefront of everyone’s minds, then making space to discuss how these commonly identified issues were affecting those residing MO-AFP.ORG 27

in other states, was both cathartic and enlightening!”

The Missouri Reception for all Missouri students, residents, and residency programs was a great way to get to know other current and future Missouri family physicians. Alternate Resident and Alternate Student MAFP Board Members were elected at Missouri Reception. This is a two-year commitment as alternate directors ascend to board members. Congratulations to: Student Board Member: Abby Crede, University of Missouri – Kansas City Alternate Student Board Member: Mikala Cessac, University of Missouri – Columbia Resident Board Member: Kelly Dougherty, MD, Mercy FMR, St. Louis Alternate Resident Board Member: Noah Brown, MD, Mercy FMR, St. Louis The student congress, along with the National Congress of Family Medicine Residents, during the NCFMRS for discussions and votes that ask the AAFP to take action on issues of concern.

Many of the resolutions pertained to women’s health and the care of infants and children. The authors of one resolution cited evidence that many low-income families lack adequate access to diapers. In response, delegates adopted a substitute resolution in support of efforts to close the “diaper gap” through legislation and

regulation, direct subsidies, support for community resources and other interventions.

Another resolution, which was amended and adopted on the floor, asked the AAFP to expand access to preventive cancer screening by developing resources and guidelines to educate and encourage members to provide shared decision making on heritable cancer gene screening.

A resolution on rural medicine asked the AAFP to advocate for the expansion of existing rural family medicine residencies and the creation of new residencies.

Delegates also adopted other measures requesting that the Academy advocate for the use of International Confederation of Midwives educational standards as the baseline for midwifery education, training and licensure; provide education about fertility awareness-based methods through women’s health CME programs and the Academy’s patient-centered companion website, familydoctor.org; and develop new policy that defines pregnancy crisis centers and ensures that information about these facilities is readily accessible to members and patients.

Final reports from the student congress detail discussions and votes about measures addressing other topics, including responsibilities of student members appointed to the Commission on Federal and State Policy; expanded education activities on integrative medicine; and support for chapters advocating for preventive service coverage.

Karstan Luchini, MD, MAFP Student Board Member AAFP National Conference is an exciting experience for Family Doctors in training. There are so many opportunities available for networking, learning, and leading. This year, I spent my time at AAFPNC attending lectures on topics that challenged the way I think and challenged myself to gain new perspectives. I attended resident and student congress and worked with other representatives from Missouri to draft a resolution. I nominated a friend for a national leadership position and met with AAFP board members to discuss hot topics in Family Medicine. The most fun I had, however, was reconnecting with my friends from across the state at Missouri Street in the exhibition hall. I hope to continue to explore all AAFP NC has to offer in years to come!

Kelly Dougherty, PGY2, Mercy FMR, MAFP Alternate Resident Director I am so thankful for MAFP helping to sponsor my time at AAFP National Conference for Residents and Students.

This allowed me to experience so much growth both personally and professionally by running for an elected office with the AAFP Foundation Board of Trustees. Participating in Resident Congress and networking throughout the election process allowed me to connect with so many amazing colleagues! I also gained a lot of confidence in public speaking and in my knowledge of the resident congress process. I am so excited to represent Missouri on the AAFP Foundation Board of Trustees, and so thankful to have the support of my state chapter.

Abby Crede, UMKC, MAFP Alternate Student Director I had the pleasure of attending national conference this year with the generous support of the Missouri Academy of Family Physicians. This is an event I greatly look forward to each year as it is a great time to meet with faculty and residents at almost every family practice residency you can think of! The speakers and topics are always top notch and provide great info to students of any year in medical school. I can attest to this as I was privileged to attend the conference during my third and fourth years of medical school. During my third year I was able to gain early exposure to programs and get a general understanding of the application process. During my fourth year, I was able to learn more intricate details of the application process and bring more specific questions to residents and faculty. I look forward to attending the conference as a resident next year and hopefully impact young medical students the same way previous residents impacted me!

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MAFP Starts a Family Medicine Residency Collaborative The Missouri Academy of Family Physicians and the 12 family medicine residencies in the state are working to build stronger relationships through the creation of a statewide family medicine leadership collaborative. These relationships will identify opportunities to support the residency programs and residents, as well as strengthen our recruitment and retention efforts of residents and our new family physicians.

A survey of our family medicine residency programs to determine their interest in participating in this type of collaborative was a resounding YES! Based on this response, MAFP applied for and was awarded two grants. We were awarded a grant from the AAFP Foundation and the American Board of Family Medicine (ABFM) Constituent Chapter Pilot Grant to start building the collaborative.

This proposal supports the ABFM Strategic Priority #4 to support medical education (e.g., identifying new ways of increasing student interest in family medicine; enhancing resident education; using ABFM data to advocate for GME in your state; post-graduate leadership programs; etc.)

This plan is an opportunity to build on the informal support and activities currently provided by the MAFP for family medicine residency programs. We will facilitate opportunities to promote excellence in family medicine residency education by connecting residency directors and chief residents to help with knowledge sharing, support, leadership development, collaborative learning, and residency expansion. This group will help residencies stay informed about the activities of the MAFP, ABFM, and ACGME, provide guidance to the MAFP leadership regarding issues and opportunities, and ensure we graduate well-trained family medicine physicians to serve Missourians.

Currently, there is not an ongoing forum to facilitate the connection of residency directors or chief residents at the state level in Missouri. During the 2022 MAFP strategic planning session, the board (which includes some residency directors) identified a strong need for this program to facilitate shared learning of best practices and innovation while developing a more robust network of family medicine leaders. The MAFP board of directors determined that connecting Missouri’s residency directors and chief residents is a high priority in order to provide a collaborative environment to facilitate research, advocacy, resource sharing, graduate medical education, certification, and other opportunities of mutual interest.

The upcoming ABFM and ACGME changes are an example of how and why residencies can work together and learn from each other during the implementation of these changes.

We are at the beginning stages of this initiative and are planning our first meeting. Once this forum is established, we anticipate regular discussion among program directors, chief residents, and MAFP through formal and informal communications. This will strengthen our education, training, and community among programs and with the ABFM. We plan to facilitate meetings held in conjunction with existing meetings at the national and state levels.

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GME: We are Expanding in Missouri Kathy Pabst, MBA, CAE, MAFP Executive Director As you may recall from previous issues and reports from the Missouri Academy of Family Physicians (MAFP), we have actively pursued expanding the number of primary care residency spots in Missouri, specifically family medicine, through a bill introduced and passed in the 2023 state legislative session. We worked closely with our state legislators and other stakeholders to bring this concept to fruition, along with $2.3 million in general revenue funding to support the program.

Missouri’s highly successful recruitment of medical students has created an excess of medical students for the limited residency slots in family medicine. According to allopathic and osteopathic enrollment data, medical school enrollments have increased 12% since the 2015-16 academic year; and medical school graduates have increased 8%. During this same time period, residency slots have not kept pace with the number of medical students graduating in Missouri resulting in an export of medical students to other states.

The MAFP conducted a survey of the 10 Missouri family medicine residency programs to determine their capacity to increase residency slots in their respective programs. Two additional family medicine residency programs were opened in the state during the survey process. Based on the survey results, these 12 residency programs combined have the capacity to train a total of 239 family medicine residents, approximately 80 per year. Based on these survey results, 80% of family medicine residency programs have the capacity to expand their residency slots for a total of 17 each year of the threeyear program. This would create 51 additional family physicians over a three-year period. This increase does raise the cost per resident per year. These direct costs include the resident’s base salary, benefits, and faculty time. Seventeen new physicians could serve 37,400 Missourians based on an average patient panel size of 2,200.

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Residency programs must request approval to start or expand residency programs from the Accreditation Council for Graduate Medical Education (ACGME). Due to the time and financial constraints of starting a new residency program, this legislation is based on expanding existing programs in the state. Other barriers to implementing the program include increased faculty, long-term funding, scope of practice for family physicians in hospitals (i.e., obstetrics), additional physical space needed for larger residency classes, their patient panel size, and the clinic space to accommodate extra physicians. In addition, identifying partner clinical sites with sufficient clinical volume in maternity care and pediatrics to meet residency standards is difficult.

The Missouri Department of Health and Senior Services quickly rolled out a grant program to implement this legislation. A webinar on the program’s logistics was held and a recording can be found on the DHSS website at http://health.mo.gov/GME, or YouTube at https://youtu.be/8Nv_isLYVoo. They project the expansion to begin in June/July 2024 in family medicine, internal medicine, obstetrics/ gynecology, pediatrics, and psychiatry. The timeline for this program is very tight with the grant application deadline November 22, 2023.

Grant recipients will be notified by January 4, 2024. Funding for the entire length of residency at $75,000 per resident per training year will be provided for a new PGY1 in June 2024.

The application portal for the Missouri GME Grant Program is now open. Submit your application online at https://missouriwic. iad1.qualtrics.com/jfe/form/SV_54qtbTEpExtewx8. Additional information can be found at https://health.mo.gov/gme. Questions should be directed to the Workforce Development Manager, GME@ health.mo.gov, or by phone at (573) 751-6441.

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MEMBERS IN THE NEWS

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review.

We love to hear from our members!

Dougherty Appointed to Leadership Role with AAFP Foundation

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he American Academy of Family Physicians (AAFP) Board of Directors recently selected Kelly Dougherty, MD, to serve as the resident representative to the AAFP Foundation Board of Trustees. Her term will officially begin at this year’s Congress of Delegates October 25-27 and run through the 2024 Congress of Delegates September 22-25. Dr. Dougherty is a PGY-2 at Mercy Family Medicine Residency in St. Louis, MO. Dr. Dougherty is also the Resident Director on the MAFP board.

The American Academy of Family Physicians Foundation advances family medicine through philanthropy, using humanitarian, educational, and scientific programming to improve health.

Learn more at https://www.aafpfoundation.org/home.html.

Congratulations, Dr. Dougherty!

BOTHWELL-UNIVERSITY OF MISSOURI

RURAL FAMILY MEDICINE RESIDENCY FIRST-YEAR RESIDENTS

ShiAnne Farris, DO

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Logan Stiens, MD

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SECOND-YEAR RESIDENTS

Brittany Pendergraft, MD

Levi Harris, DO

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FAMILY MEDICINE RESIDENTS 2023-2024

Kayla Beashore, DO PGY-3

Neil Bobenhouse, DO PGY-3

Max Hesse, MD PGY-3

Jason Woody, DO PGY-3

Alex Downey, DO PGY-2

Grant Paterson, DO PGY-2

Allison Politsch, DO PGY-2

Charles Shipley, DO PGY-2

Kailyn Baalman, MD PGY-1

Nicholas Gutzmer, DO PGY-1

Kirstie Mabitad, DO PGY-1

Efren Shahabeddin, MD PGY-1

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References

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Substance Abuse and Mental Health Services Administration. Waiver Elimination (MAT Act). Last Updated June 7, 2023. Accessed July 19, 2023. https://www. samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act

Five Practical Strategies for Managing Pain in Patients with Opioid Use Disorder on Buprenorphine

Pain, Cannabis, and Safety in a Recreational Cannabis State

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Substance Abuse and Mental Health Services Administration. (2022). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Accessed July 18, 2023. https://www.samhsa.gov/data/ report/2021-nsduh-annual-national-report Missouri Department of Mental Health. 2023 Status Report on Missouri’s Substance Use and Mental Health. Accessed July 18, 2023. https://dmh.mo.gov/ alcohol-drug/reports/status-report/2023 Hser YI, Mooney LJ, Saxon AJ, Miotto K, Bell DS, Huang D. Chronic pain among patients with opioid use disorder: Results from electronic health records data. J Subst Abuse Treat. 2017;77:26-30. doi:10.1016/j.jsat.2017.03.006 Latif, Z.-E.H., Skjærvø, I., Solli, K.K. and Tanum, L. (2021), Chronic Pain Among Patients With an Opioid Use Disorder. Am J Addict, 30: 366-375. https://doi. org/10.1111/ajad.13153 Larochelle MR, Bernson D, Land T, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.

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Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872882. doi:10.1001/jama.2018.0899 Centers for Disease Control and Prevention. Nonopioid Therapies. Last Reviewed November 3, 2022. Accessed July 19, 2023. https://www.cdc.gov/opioids/ patients/options.html Buresh M, Ratner J, Zgierska A, Gordin V, Alvanzo A. Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations. J Gen Intern Med. 2020;35(12):3635-3643. doi:10.1007/s11606-020-06115-3 Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend. 2019;197:78-82. doi:10.1016/j.drugalcdep.2018.12.030 Ross S, Peselow E. Co-occurring psychotic and addictive disorders: neurobiology and diagnosis. Clin Neuropharmacol. 2012;35(5):235-243. doi:10.1097/ WNF.0b013e318261e193.

Hakobyan S, Vazirian S, Lee-Cheong S, Krausz M, Honer WG, Schutz CG. Concurrent Disorder Management Guidelines. Systematic Review. J Clin Med. 2020;9(8):2406. Published 2020 Jul 28. doi:10.3390/jcm9082406 Crotty K, Freedman KI, Kampman KM. Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder [published correction appears in J Addict Med. 2020 May/Jun;14(3):267]. J Addict Med. 2020;14(2):99-112. doi:10.1097/ADM.0000000000000635 Warner NS, Warner MA, Cunningham JL, et al. A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery. Mayo Clin Proc. 2020;95(6):1253-1267. doi:10.1016/j. mayocp.2019.10.007 Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology. 2017;126(6):1180-1186. doi:10.1097/ ALN.0000000000001633 Leighton BL, Crock LW. Case Series of Successful Postoperative Pain Management in Buprenorphine Maintenance Therapy Patients. Anesth Analg.

2017;125(5):1779-1783. doi:10.1213/ANE.0000000000002498 Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021;46(10):840-859. doi:10.1136/rapm-2021-103007 MISSOURI FAMILY PHYSICIAN October - December 2023

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Atakan Z. Cannabis, a complex plant: different compounds and different effects on individuals. Ther Adv Psychopharmacol. 2012 Dec;2(6):241-54. doi: 10.1177/2045125312457586. PMID: 23983983; PMCID: PMC3736954.

Study Reveals Inaccurate Labeling of Marijuana as Hemp. National Institute of Justice. Accessed April 22, 2023. https://nij.ojp.gov/topics/articles/studyreveals-inaccurate-labeling-marijuana-hemp#:~:text=According%20to%20 the%20new%20federal National Institute on Drug Abuse. Cannabis (Marijuana) DrugFacts. Available at: https://nida.nih.gov/publications/drugfacts/cannabis-marijuana Benedikt Fischer, Cayley Russell, Pamela Sabioni, Wim van den Brink, Bernard Le Foll, Wayne Hall, Jürgen Rehm, and Robin Room, 2017: Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations.

American Journal of Public Health 107, e1_e12, https://doi.org/10.2105/ AJPH.2017.303818 Azcarate, P.M., Zhang, A.J., Keyhani, S. et al. Medical Reasons for Marijuana Use, Forms of Use, and Patient Perception of Physician Attitudes Among the US Population. J GEN INTERN MED 35, 1979–1986 (2020). https://doi.org/10.1007/ s11606-020-05800-7 Khademi S, Hallinan CM, Conway M, Bonomo Y. Using Social Media Data to Investigate Public Perceptions of Cannabis as a Medicine: Narrative Review.

J Med Internet Res. 2023 Feb 27;25:e36667. doi: 10.2196/36667. PMID: 36848191. https://ballotpedia.org/Missouri_Amendment_3,_Marijuana_Legalization_ Initiative_(2022) https://ballotpedia.org/Missouri_Amendment_3,_Marijuana_Legalization_ Initiative_(2022) U.S. Food and Drug Administration. FDA and Cannabis Research and Drug Approval Process. Available at: https://www.fda.gov/news-events/publichealth-focus/fda-and-cannabis-research-and-drug-approval-process Department of Justice/Drug Enforcement Administration. WHAT IS MARIJUANA? WHAT IS ITS ORIGIN? What Are Common Street Names? What Does It Look Like? 2020. https://www.dea.gov/sites/default/files/2020-06/MarijuanaCannabis-2020_0.pdf Gazendam A, Nucci N, Gouveia K, Abdel Khalik H, Rubinger L, Johal H. Cannabinoids in the Management of Acute Pain: A Systematic Review and Meta-analysis. Cannabis Cannabinoid Res. 2020;5(4):290-297. doi:10.1089/ can.2019.0079 Blake A, Wan BA, Malek L, DeAngelis C, Diaz P, Lao N, Chow E, O’Hearn S. A selective review of medical cannabis in cancer pain management. Ann Palliat Med. 2017 Dec;6(Suppl 2):S215-S222. doi: 10.21037/apm.2017.08.05. Epub 2017 Aug 23. PMID: 28866904.

Andreae MH, Carter GM, Shaparin N, et al. Inhaled Cannabis for Chronic Neuropathic Pain: A Meta-analysis of Individual Patient Data. J pain.

2015;16(12):1221-1232. doi: 10.1016/j.jpain.2015.07.009 Fitzcharles M-A, Ste-Marie PA, Häuser W, et al. Efficacy, Tolerability, and Safety of Cannabinoid Treatments in the Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials. Arthritis Care Res (Hoboken). 2016;68(5):681688. doi:10.1002/acr.22727 Johal H, Devji T, Chang Y, Simone J, Vannabouathong C, Bhandari M. Cannabinoids in Chronic Non-Cancer Pain: A Systematic Review and Meta-Analysis. Clin Med Insights Arthritis Musculoskelet Disord. 2020; 13:1179544120906461. doi:10.1177/1179544120906461 Yanes JA, McKinnell ZE, Reid MA, et al. Effects of cannabinoid administration for pain: A meta-analysis and meta-regression. Exp Clin Psychopharmacol.

2019;27(4):370-382.

Andreae MH, Carter GM, Shaparin N, et al. Inhaled Cannabis for Chronic Neuropathic Pain: A Meta-analysis of Individual Patient Data. J pain.

2015;16(12):1221-1232. doi: 10.1016/j.jpain.2015.07.009 Mücke M, Phillips T, Radbruch L, Petzke F, Häuser W. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2018 Mar 7;3(3):CD012182. doi: 10.1002/14651858.CD012182.pub2.

Ang, S.P., Sidharthan, S., Lai, W. et al. Cannabinoids as a Potential Alternative to Opioids in the Management of Various Pain Subtypes: Benefits, Limitations, and Risks. Pain Ther (2023). https://doi.org/10.1007/s40122-022-00465-y Fitzcharles M-A, Ste-Marie PA, Häuser W, et al. Efficacy, Tolerability, and Safety of Cannabinoid Treatments in the Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials. Arthritis Care Res (Hoboken). 2016;68(5):681-

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Ang, S.P., Sidharthan, S., Lai, W. et al. Cannabinoids as a Potential Alternative to Opioids in the Management of Various Pain Subtypes: Benefits, Limitations, and Risks. Pain Ther (2023). https://doi.org/10.1007/s40122-022-00465-y Gazendam A, Nucci N, Gouveia K, Abdel Khalik H, Rubinger L, Johal H. Cannabinoids in the Management of Acute Pain: A Systematic Review and Meta-analysis. Cannabis Cannabinoid Res. 2020;5(4):290-297. doi:10.1089/ can.2019.0079 Ang, S.P., Sidharthan, S., Lai, W. et al. Cannabinoids as a Potential Alternative to Opioids in the Management of Various Pain Subtypes: Benefits, Limitations, and Risks. Pain Ther (2023). https://doi.org/10.1007/s40122-022-00465-y Johal H, Devji T, Chang Y, Simone J, Vannabouathong C, Bhandari M. Cannabinoids in Chronic Non-Cancer Pain: A Systematic Review and Meta-Analysis. Clin Med Insights Arthritis Musculoskelet Disord. 2020; 13:1179544120906461. doi:10.1177/1179544120906461 Gazendam A, Nucci N, Gouveia K, Abdel Khalik H, Rubinger L, Johal H. Cannabinoids in the Management of Acute Pain: A Systematic Review and Meta-analysis. Cannabis Cannabinoid Res. 2020;5(4):290-297. doi:10.1089/ can.2019.0079 Shah S, Schwenk ES, Sondekoppam RV, Clarke H, Zakowski M, Rzasa-Lynn RS, Yeung, B., Nicholson, K., Schwartz, G., Hooten, W. M., Wallace, M., Viscusi, E. R., & Narouze, S. (2023). ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med, 48(3), 97-117. https://doi.org/10.1136/rapm-2022-104013 Benedikt Fischer, Cayley Russell, Pamela Sabioni, Wim van den Brink, Bernard Le Foll, Wayne Hall, Jürgen Rehm, and Robin Room, 2017: Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations.

American Journal of Public Health 107, e1_e12, https://doi.org/10.2105/ AJPH.2017.303818

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Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine 2007;41:211-216.

L Ohberg, R Lorentzon, H Alfredson. Eccentric training in patients with chronic Achilles tendinosis: normalized tendon structure and decreased thickness at follow up. British Journal of Sports Medicine 2004;38:8–11.

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An Osteopathic Approach to Temporomandibular Joint Pain

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