Oklahoma DO January 2014 by Oklahoma Osteopathic Association

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA D.O.

May/June 2013 January 2014

Volume 78, No. 7

•Legislative Report •114th Annual Convention Program Oklahoma D.O. | January 2014

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•Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting

Oklahoma D.O.

IN THIS ISSUE:

WE KNOW OKLAHOMA HEALTHCARE AT PLICO, WE ARE HONORED TO INVEST IN OSTEOPATHIC EDUCATION AND COMMITTED TO PROTECTING YOU THROUGHOUT YOUR CAREER IN MEDICINE.

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Oklahoma D.O. PAGE 2

— KIRK JEWELL, PRESIDENT, OKLAHOMA STATE UNIVERSITY FOUNDATION

PLICO 405.815.4800 PLICO - OK.COM FINANCIAL STABILITY RATING ® OF A, EXCEPTIONAL Oklahoma D.O. | January 2014

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA

May/June 2012 May/June 2013 January 2014

D.O.

Volume 78, No. 7

January 2012

Lynette C. McLain, Editor Marie Kadavy, Associate Editor

OOA Officers: Bret S. Langerman, DO, President (South Central District) Michael K. Cooper, DO, FACOFP, President-Elect (Northeastern District) C. Michael Ogle, DO, Vice President (Northwest District) Layne E. Subera, DO, FACOFP, Past President (Tulsa District) OOA Trustees: Kenneth E. Calabrese, DO, FACOI (Tulsa District) Dale Derby, DO (Tulsa District) Melissa A. Gastorf, DO (Southeastern District) Timothy J. Moser, DO, FACOFP (South Central District) Gabriel M. Pitman, DO (South Central District) Christopher A. Shearer, DO, FACOI (Northwest District) Kayse M. Shrum, DO, FACOP (Tulsa District) Ronald S. Stevens, DO (Eastern District) OOA Central Office Staff: Lynette C. McLain, Executive Director Lany Milner, Director of Operations and Education Matt Harney, MBA, Advocacy and Legislative Director Marie Kadavy, Director of Communications and Membership

The Oklahoma D.O. is published monthly from the Oklahoma Osteopathic Association Central Office: 4848 N. Lincoln Blvd., Oklahoma City, OK 73105-3335. Marie Kadavy, Graphic Designer and Associate Editor

The OOA Website is located at www.okosteo.org

Oklahoma D.O. | January 2014

OSU Medical Center transferred to state trust

OEFOM Update provided by Robin R. Dyer, DO, 2013-2014 OEFOM President

Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting

Legislative Report provided by Matt Harney, MBA

OOPAC Contribution Form

What DO’s Need To Know

46 “Treatment of Newly Diagnosed Diabetes Patients After Bypass Surgery” 49

Bureau News

“Your Pneumonia Protection Plan” provided by the American Osteopathic Association

2013-2014 OOA Directory Order Form

January Birthdays

114th Annual Convention Program

62 Classifieds 63

Calendar of Events

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For more information: 405.528.4848 or 800.522.8379 Fax: 405.528.6102 E-mail: ooa@okosteo.org

“It’s Time to Get Involved!” provided by Bret S. Langerman, DO, 2013-2014 President

Oklahoma D.O.

Copy deadline is the 10th of the month preceding publication. Advertising copy deadline is the 15th of the month preceding publication.

BRET S. LANGERMAN, DO President 2013 – 2014 oklahoma osteopathic association it’s time to get involved!

T Oklahoma D.O. PAGE 4

The holidays have come and gone and winter is well upon us now. I hope that you and your family have had a safe and fruitful season and that this finds you well. As we look forward to the next few months, we will see the start of the legislative session. The deadline for introduction of bills for consideration in this session was Jan. 16, 2014, with the actual opening of the legislature beginning on Feb. 3, 2014. As always, there are literally hundreds of bills that will be introduced in this (and every) session that affect what we do as physicians in our practices. The OOA by way of our lobbyists and Bureau on Legislation will track all of these bills through the legislative process. We will continue to lobby to protect our practice rights as physicians as well as the rights of those patients that we serve. Routinely, issues arise at the legislature that will require your help as physicians and members of this association. The OOA, through legislative updates and the OOA Touch blog, will keep you informed about such issues and may call on you to contact your elected officials to lobby for our causes. If you do not know your local representatives and senators, I urge you to identify them. You can look them up under the Legislation tab of our website. Make a point to meet them and offer your expertise in such matters. Osteopathic Medicine Day at the State Capitol will be held on March 3, 2014, and we invite you to join forces with us to make our presence known. This

is a great opportunity to have your voice heard. If you need guidance or further information, the OOA stands ready to help and can be a resource for you. Grassroots efforts in the legislative process do pay off and have a positive effect for us all. Speaking of grassroots, the OOA may be visiting your district soon. We are currently in the process of trying to make our districts more robust and more active in the happenings of the OOA. After all, you and your districts are what make the OOA strong. Representatives from the OOA have been roaming the state visiting districts and holding meetings offering CME activities. To this point, we have been to the Tulsa, Eastern, Northeastern, Southeastern, North Central and Northwest districts with plans to visit the Southern and Southwestern districts in the near future. The OOA central office can provide you with exact dates, times and locations. Good eats and good times have been had by all. I encourage you to participate in these meetings and get involved in your districts and in the OOA. The Winter CME Seminar titled “ABC’s of LAB’s: What’s New, What’s Hot and What’s Not,” which was held at the Hard Rock Hotel & Casino in Catoosa, Okla., was a great success. I thank Dr. Allen for chairing and organizing this meeting. The turnout was outstanding, and talks received high reviews. DO OK

Oklahoma D.O. | January 2014

Despite the final score, current and former ooa leadership Enjoyed the Oklahoma State University College of Osteopathic Medicine Suite during the Dec. 7, 2013, Bedlam game vs. the University of Oklahoma LeRoy E. Young, DO • Richard W. Schafer, DO • OOA President Bret S. Langerman, DO • OOA Trustee and OSU-CHS President Kayse M. Shrum, DO • OOA Trustee Gabriel M. Pitman, DO • Regent Trudy J. Milner, DO

Richard W. Schafer, DO • Beverly Schafer • Kayse M. Shrum, DO

LeRoy E. Young, DO • Cindy Young • DeLaine Langerman • Bret S. Langerman, DO • Christa Pitman • Gabriel M. Pitman, DO

Oklahoma D.O.

LeRoy E. Young, DO • Gabriel M. Pitman, DO • Bret S. Langerman, DO

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LeRoy E. Young, DO • Bret S. Langerman, DO • Kayse M. Shrum, DO • Gabriel M. Pitman, DO • Trudy J. Milner, DO

Oklahoma D.O. | January 2014

OSU MEDICAL CENTER TRANSFERRED TO STATE TRUST

The Oklahoma State University Medical Center (OSUMC) has been transferred from a trust owned by the City of Tulsa to a state trust, the OSU Medical Center Trust. This change was effective Dec. 6, 2013, and has been approved by Governor Mary Fallin and Attorney General Scott Pruitt. The state legislature required this change in 2013 as a part of the $13 million appropriation for the hospital. OSU Medical Center is the teaching hospital for the OSU College of Osteopathic Medicine. In a statement, Jerry Hudson, Chair of the OSU Medical Center Trust said, “while OSU Medical Center will continue to provide vital health care services to the citizens of Tulsa, our medical center staff treats patients from across the state through the use of telemedicine and other services. The transition to a state agency will enhance our ability to be seen as a statewide partner in health care in Oklahoma.”

ment of health care in Oklahoma that we have a teaching hospital working hand-in-hand with our medical school.” OSU Medical Center brings to fruition the osteopathic medicine commitment to serve the underserved. The medical center provided nearly $25 million in indigent care last year and processes more than 46,000 emergency room visits annually. OSU Medical Center is the largest osteopathic teaching hospital in the country, training 154 residents. OSUMC is the only public teaching hospital in the nation that does not receive recurring annual revenue from the public sector. The average subsidy for a public teaching hospital is $34 million. The University Hospital Authority, which provides funding for the OU Medical Center, received a $125 million appropriation for fiscal year 2013. OSUMC is currently in discussions with private partners and will be seeking funds from the state legislature. DO OK

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The transition to a state trust represents recognition from the state legislature that OSUMC serves not just the Tulsa area, but ultimately serves the entire state. In the last decade, OSU Medical Center has contributed $136 million to the state’s economy and created more than 2,500 jobs. OSU Center for Health Sciences President Kayse M. Shrum, DO, said “one of the primary factors that determines where doctors will set up their practice is where they complete their residency and the OSU Medical Center provides the majority of the residency slots for our students. It is essential for the success of our students and the improve-

Oklahoma D.O. | January 2014

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Oklahoma D.O. | January 2014

robin r. dyer, do President 2013 â&#x20AC;&#x201C; 2014

oklahoma educational foundation for osteopathic medicine

Greetings from your OEFOM Board! With the blast of winter weather in early December, our quarterly meeting was held primarily via conference call....how did we get through medical school without the technology we now have available?! We are very excited to announce that this April, at the OOA 114th Annual Convention, the OEFOM will be teaming up with the OOA Board to bring back golf AND tennis tournaments! Each will be hosted at the Oak Tree Country Club in Edmond, Okla. So for those of you who prefer swinging a racket instead of a golf club.... Get practicing!

Your continued monetary support to OEFOM, honoring or remembering someone in our osteopathic family, is what allows us to provide these scholarships to our young future colleagues! Lastly, I hope you all had a wonderful Christmas and New Yearâ&#x20AC;&#x2122;s with your family and friends. I look forward to 2014 and all the exciting adventures it has in store for us! Thanks again for the privilege of serving this year as your OEFOM Board President! DO OK

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The scholarship committee will be reviewing each application submitted and will choose students to receive scholarships for the 2014-2015 school year. These scholarships will be awarded during the 114th Annual Convention held at the Norman Embassy Suites on April 26.

Oklahoma D.O. | January 2014

memorium

VERGIL D. SMITH, DO Vergil Don Smith, DO, 82, of Marietta, was born Dec. 10, 1930, in Seminole, the son of Vergil Eagon Smith and Nathamay Brown Smith. He passed away Monday, Dec. 9, 2013, near his home in Marietta. A 1948 graduate of Claremore High School, he then attended Oklahoma A&M. He also graduated from the College of Osteopathic Medicine of Kansas City, Mo., in 1961. As a doctor of osteopathic medicine, Dr. Smith practiced one year in Tulsa, and then moved to Marietta in 1963. In addition to practicing here for 50 years, he was instrumental in getting a hospital for Marietta. In 1995-96, Dr. Smith was honored as the OAPA Physician of the Year, and in 2001, recognized as a life member of the Oklahoma Osteopathic Association. As a veteran of the Korean Conflict, he served in the U.S. Air Force as a radio repairman. In 1971, he received his pilot’s license and, in 1992, commercial pilot training and commercial license instrument rating. In 2003, Dr. Smith received CE-500 citation jet training. In addition, he was recognized by the FAA as a certified medical examiner. Dr. Smith and the former Marilyn Howland were married in Oklahoma City, on Jan. 15, 2005. Preceding him in death were his parents; wife Judy Smith on Sept. 27, 2001; and brother Tommy Lee Smith. Survivors include his wife, Marilyn of the home; four sons and daughter-in-law; four daughters and sons-in-law; 17 grandchildren; two great-grandchildren; and a number of other family members and friends.

ROBERT G. PATZKOWSKY, DO Robert Gene Patzkowsky, DO, 79, was welcomed into God’s arms on Friday, Dec. 20, 2013, surrounded by his family. Dr. Patzkowsky, also known by many as “Dr. Pat”, was a loving husband, devoted father, grandfather, cherished friend and respected physician. Born on Oct. 21, 1934, in Enid to Ruben and Esther Patzkowsky, Dr. Patzkowsky and his twin brother, Paul, were raised in Fairview.

Dr. Patzkowsky was also humbled by the many honors and achievements throughout his career. He served as past president to several osteopathic boards and earned his fellowship in surgery. In 1999, he was awarded the Doctor of the Year award for outstanding service by the Oklahoma Osteopathic Association. He was also selected to be on the Oklahoma Peer Review Board and served as past president.

Oklahoma D.O. | January 2014

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He married Charlette Gillham in 1976. It was the beginning of a lifelong loving relationship that spanned 37 years. They raised their two daughters, Shawna and Robbi, with great pride. In recent years, they have enjoyed their precious grandsons, and his grandsons loved their Poppy. As a family, they shared Dr. Patzkowsky with the Ardmore community because he loved his patients and his patients loved him. His contributions and caring spirit will forever live on in the many lives he touched, and the service he has given. He is survived by his devoted wife, Charlette; two daughters and sons-in-law; two grandsons; two stepsons; and numerous family and friends.

Oklahoma D.O.

Following graduation from high school, Robert obtained his Bachelor of Science degree from Southwestern State College. In 1961, he graduated from the Osteopathic College of Medicine in Kansas City, Mo. That following year he began his practice in Ardmore, at “The Doctors Clinic.” He also practiced as a boardcertified surgeon and obstetrician in Ardmore and the surrounding towns of Healdton, Madill, Sulphur and Marietta.Throughout his 52 years of practice, his philosophy of medicine remained the same. He said, “To be a good physician you have to enjoy people. Sure, it’s a science, but when it comes down to it, it’s really a people business and I really like being in the business of helping people.” He touched many lives in these communities and when he retired from obstetrics, he had delivered over 4,000 babies during his career.

memorium

DAMIAN MARK RAMKARAN, OMS-IV Damian Mark Ramkaran, OMS-IV, was born April 25, 1985, in Trinidad, West Indies, and passed away Dec. 27, 2013, with his family by his bedside. He moved with his family to New Jersey in 1987 and to Tulsa in 1992 and attended Jenks High School. Ramkaran overcame significant obstacles in order to achieve his dreams. After winning his battle with nasopharyngeal cancer in 2007, Ramkaran had aspirations of becoming an oncologist so that he could help those battling cancer. He graduated from Oklahoma State University and then went on to study at Oklahoma State University College of Osteopathic Medicine where he was a candidate to earn his medical degree in May 2014. His former patients, colleagues, friends and family all attested to the fact that he was a compassionate, generous and gentle person. Ramkaran married his high school sweetheart and life partner, Britney and have two children. He is survived by his loving wife, Britney; his children, Pierson (age 2) and Syri (age 1); his parents, Gupty and Donna; and his siblings, Garvin, Joel and Stephanie. He will be missed tremendously by all who were blessed to know him. A memorial fund has been established in Damian Ramkaranâ&#x20AC;&#x2122;s memory at Stillwater National Bank for individuals wishing to donate to help offset any expenses and offer support for his childrenâ&#x20AC;&#x2122;s future education costs. All donations will go directly to his wife and two children. Please make donations out to Damian Mark Ramkaran Benefit Fund. Donations can also be mailed to: Stillwater National Bank PO Box 521500 Tulsa, OK 74152

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Contributing

n OEFOM Memorials n

Dr. Frank and Mary Shaw Dr. David and Rita Hitzeman Drs. Tony and Sharon Little Dr. Geron and Sheila Meeks Dr. Geron and Sheila Meeks Minta Z. Tauer, DO Mike and Marsha Zulkey Martha Zulkey Mrs. Leroy Zulkey

In Memory of

Edwin A. Berger, DO Jeanne Edwards Mary Hughes Robert G. Patzkowsky, DO Vergil D. Smith, DO Vergil D. Smith, DO Vergil D. Smith, DO Vergil D. Smith, DO Vergil D. Smith, DO

Oklahoma D.O. | January 2014

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Oklahoma D.O. | January 2014

3/28/11 11:05 AM

Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting Note: These guidelines do not replace clinical judgment in the appropriate care of patients. They are not intended as standards of care or as templates for legislation, nor are they meant for patients in palliative care programs or with cancer pain. The recommendations are an educational tool based on the expert opinion of numerous physicians and other health care providers, medical/nursing boards, mental and public health officials, and law enforcement personnel in Oklahoma and throughout the United States. The guidelines are available at http://poison.health.ok.gov.

Opioid Treatment for Acute Pain 1. Opioids should only be used for treatment of acute pain when the severity of the pain warrants that choice and after determining that other non-opioid pain medications or therapies will not provide adequate pain relief. 2. Providers should query the Oklahoma Prescription Monitoring Program (PMP) for patients presenting with acute pain, prior to prescribing an opioid medication. In circumstances where a patient’s pain is resulting from an objectively diagnosed disease process or injury, a provider may prudently opt not to review the Oklahoma PMP. 3. When opioids are prescribed for treatment of acute pain, the number of doses dispensed should be no more than the number of doses needed based on the usual duration of pain severe enough to require opioids for that condition. 4. When opioids are prescribed for treatment of acute pain, the patient should be counseled to store the medications securely and never to share with others. In order to prevent non-medical use of the medications, it is also recommended that patients dispose of medications when the pain has resolved. 5. Long duration-of-action opioids (e.g., methadone, buprenorphine, fentanyl, extended release oxycodone, and morphine) are rarely indicated for treatment of acute pain. 6. The use of opioids should be re-evaluated carefully, including assessing the potential for abuse, if persistent pain suggests the need to continue opioids beyond the anticipated time period of acute pain treatment for that condition. Health care providers should query the Oklahoma PMP as part of this re-evaluation process. 7. Health care providers should generally not provide replacement prescriptions for opioids that have been lost, stolen, or destroyed.

Opioid Treatment for Chronic Pain 1. Alternatives to opioid treatment should be tried, or previous attempts documented, before initiating opioid treatment.

3. The health care provider should screen for risk of abuse or addiction before initiating opioid treatment.

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4. Prior to the initial prescribing of opioid medications, health care providers should query the Oklahoma Prescription Monitoring Program (PMP).

Oklahoma D.O.

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Oklahoma D.O. | January 2014

Background Prescription drug abuse is Oklahomaâ&#x20AC;&#x2122;s fastest growing drug problem. Of the nearly 3,200 unintentional poisoning deaths in Oklahoma from 2007-2011, 81% involved at least one prescription drug.1 In 2010, Oklahoma had the fourth highest unintentional poisoning death rate in the nation (17.9 deaths per 100,000 population).2 Prescription painkillers (opioids) are now the most common class of drug involved in overdose deaths in Oklahoma (involved in 87% of prescription drug-related deaths, with 417 opioid-involved overdose deaths in 2011).1 In a 2010 National Survey on Drug Use and Health report, Oklahoma led the nation in nonmedical use of painkillers, with more than 8% of the population age 12 and older abusing/misusing painkillers.3 Oklahoma is also one of the leading states in prescription painkiller sales per capita.4 These guidelines were primarily adapted from the Utah Clinical Guidelines on Prescribing Opioids.5 The Opioid Prescribing Guidelines for Oklahoma Workgroup also studied other state and national recommendations in an effort to prepare guidelines most relevant to the practice of medicine in Oklahoma. The Workgroup created these guidelines in an effort to help reduce the misuse of prescription opioid analgesics while preserving patient access to needed medical treatment.

Guidelines for Acute Pain 1. Opioids should only be used for treatment of acute pain when the severity of the pain warrants that choice and after determining that other non-opioid pain medications or therapies will not provide adequate pain relief.6 Most acute pain is better treated with non-opioid medications [e.g., acetaminophen, non-steroidal antiinflammatory drugs (NSAIDs)] or physical modalities such as therapeutic exercises or stretching. Opioid medications have less desirable adverse effect profiles in acute pain patients. Care should be taken to assure that opioid treatment does not interfere with early implementation of functional restoration programs such as exercise and physical therapy. Non-medical use of opioids is more common among younger people, and these risks should be considered when prescribing to an adolescent. 2. Providers should query the Oklahoma Prescription Monitoring Program (PMP) for patients presenting with acute pain, prior to prescribing an opioid medication. In circumstances where a patientâ&#x20AC;&#x2122;s pain is resulting from an objectively diagnosed disease process or injury, a provider may prudently opt not to review the Oklahoma PMP. The Oklahoma PMP is a real-time database of scheduled prescriptions written to persons who filled a prescription in Oklahoma. The Oklahoma PMP can be accessed at: http://www.ok.gov/obndd/Prescription_Monitoring_Program/.

Prescribing more medications than necessary can lead to non-medical use, abuse, and diversion of unused Oklahoma D.O. | January 2014

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3. When opioids are prescribed for treatment of acute pain, the number of doses dispensed should be no more than the number of doses needed based on the usual duration of pain severe enough to require opioids for that condition.

Oklahoma D.O.

Patients with a history of or current substance abuse are at increased risk of misusing opioids when prescribed.7,8 Medical providers should ask the patient about a history of substance abuse prior to prescribing an opioid medication for the treatment of acute pain. A non-opioid regimen is preferred for patients presenting with a history of substance abuse who have acute pain. Although this should not exclude a patient from being prescribed opioids for acute pain, it should prompt a discussion with the patient about the potential for addiction. When a patient with a history of opioid addiction presents with acute pain due to an objectively diagnosed clinical or traumatic condition requiring the use of opioids for pain control, very close follow-up is indicated.

medications. Opioid pain medications should be discontinued when the pain severity no longer requires opioid medications. 4. When opioids are prescribed for treatment of acute pain, the patient should be counseled to store the medications securely and never to share with others. In order to prevent nonmedical use of the medications, it is also recommended that patients dispose of medications when the pain has resolved. It is important that patients understand the need to store medications securely. Health care providers should encourage patients to keep medications in a locked environment rather than in easily accessible locations, such as the bathroom or kitchen cabinet, where medications are accessible to children and can be a target for theft. After recovery from pain, leftover medications should be properly disposed of immediately to help protect the medications from being diverted. Tools to accompany Recommendation 4: 



Oklahoma Bureau of Narcotics and Dangerous Drugs Take Back Container Locations http://www.ok.gov/obndd/documents/TakeBackBoxes.pdf

5. Long duration-of-action opioids (e.g., methadone, buprenorphine, fentanyl, extended release oxycodone, and morphine) are rarely indicated for treatment of acute pain. Given the epidemiological data showing a significant increase in mortality associated with long-acting opioids, the inherent difficulty in titrating these medications, and the availability of alternative medications and/or treatment modalities, health care providers are advised to refrain from the routine use of long-acting opioids in the acute pain setting.5,9 6. The use of opioids should be re-evaluated carefully, including assessing the potential for abuse, if persistent pain suggests the need to continue opioids beyond the anticipated time period of acute pain treatment for that condition. Health care providers should query the Oklahoma PMP as part of this re-evaluation process. Patients with acute pain who fail to recover in a usual timeframe or otherwise deviate from the expected clinical course for their diagnosis should be carefully re-evaluated. The continuation of opioid treatment for acute pain in this setting may represent the initiation of opioid treatment for a chronic pain condition without being recognized as such. At this time, the diagnosis and appropriateness of the treatment plan should be re-evaluated and the patient’s medical history should be reviewed for factors that could interfere with treatment and pose a risk for complications during opioid treatment, including substance abuse or history of substance abuse. Tools to accompany Recommendation 6: Oklahoma D.O. PAGE 16



Oklahoma Prescription Monitoring Program http://www.ok.gov/obndd/Prescription_Monitoring_Program/

7. Health care providers should generally not provide replacement prescriptions for opioids that have been lost, stolen, or destroyed. Patients misusing controlled substances frequently report their opioid medications as having been lost or stolen. Pain specialists routinely stipulate in pain agreements with patients that lost or stolen controlled substances will not be replaced. Most written agreements between chronic pain patients and pain management physicians, including the Health Resources and Services Administration (HRSA) toolkit sample pain agreement, state that prescriptions for opioids will not be replaced.10 4

Oklahoma D.O. | January 2014

The diversion of prescribed opioids is common. One study looked at completed patient surveys, and found that 45% of respondents reported some form of drug diversion at least once. Stolen medication was the most prevalent method of drug diversion, with 30% of respondents reporting at least one incident of stolen medication.11 In another survey study, among persons 12 years and older who abused opioid pain medications (2009-2010), 71.2% came from friends or relatives; 55% were given to the abuser, 11.4% were purchased, and 4.8% were stolen.12,13

Guidelines for Chronic Pain 1. Alternatives to opioid treatment should be tried, or previous attempts documented, before initiating opioid treatment.6,9,13,14,15 Opioid medications are usually not the most appropriate first line of treatment for patients with chronic pain. Other measures, such as non-opioid pain medications, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g., therapeutic exercise, physical therapy), should be tried first and the outcomes of those therapies documented. Opioid therapy should be considered only when other potentially safer and more effective therapies prove inadequate. This approach is consistent with the World Health Organization’s (WHO) Pain Relief Ladder.16 1.1 Clinicians should refer to disease-specific guidelines for recommendations for treatment of chronic pain related to specific diseases or conditions. Tools to accompany Recommendation 1: 

Non-opioid Pain Management Tool http://health.utah.gov/prescription/tools.html (see Informational Tools on website)

2. A comprehensive evaluation should be performed before initiating opioid treatment for chronic pain. For chronic pain patients transferring their care to new health care providers, new opioid prescriptions should generally not be written until the previous provider’s records have been reviewed or the previous health care provider has been notified of the transfer of care.13,14,15,17 There are many reasons to prescribe cautiously when initiating opioid therapy; therefore a comprehensive initial evaluation is necessary to identify patients at high risk for adverse outcomes. The major goal should be to provide the greatest functional benefit while minimizing the potential for harm to patients. The potential for serious harm, including death, exists due either to overdose or to dangerous behaviors that may occur while taking opioids. The patient may be directly harmed, but others may also be harmed through diversion or by acts performed by a person taking opioids. Initiating opioid treatment often results in short-term relief, which may not be sustainable. Safe long-term use of opioid medications requires the commitment of adequate resources. Patients need to be monitored regularly to evaluate outcomes and identify aberrant behavior or adverse side effects. The goal of the comprehensive evaluation is to determine the nature of the patient’s pain, and to evaluate how the pain is affecting the patient’s function and quality of life. The provider should attempt to identify other conditions or circumstances that could adversely affect the treatment plan or the approach to managing the patient’s treatment plan. The provider should also re-assess and re-evaluate prior approaches to the patient’s pain management to provide a basis for establishing an effective ongoing plan of care.

Oklahoma D.O.

The evaluation should specifically assess:

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A. The character and potential cause(s) of pain, as well as prior treatments. 

The duration of the pain should be considered.



The character of the pain should be considered. Since certain types of pain, such as neuropathic pain,

Oklahoma D.O. | January 2014

might not be best treated with opioids. It is important for the clinician to consider the type and character of pain when prescribing a medication. B. Social factors and medical or mental health conditions might influence treatment, especially those that might interfere with appropriate and safe use of opioid therapy.14 

Obtain a history of substance use, addiction, or dependence. (If present, refer to Recommendations 13.2 and 13.3.)



Consider potential psychiatric conditions, including personality disorders that may affect pain or the treatment of pain. (If present, refer to Recommendation 13.4.)



Identify use of alcohol and other medications that might interact with opioid medications used to treat pain. Particular attention and caution should be given to alcohol, benzodiazepines, and other sedative medications.



Assess the presence of medical conditions that might complicate the treatment of pain, including medication allergy, cardiac or respiratory disease, and sleep apnea or risk factors for sleep apnea.



Central sleep apnea is common among persons treated with methadone and other opioid medications, especially at higher dosages. Some experts recommend that all patients who are considered for longterm opioid treatment receive a sleep study prior to therapy or when higher dosages are considered.14

C. Effects of pain on the patient’s life and function. 

Assess the patient’s baseline severity of pain, functional status, and quality of life using a valid, reliable method/instrument that can be used later to evaluate treatment effectiveness.

Tools to accompany Recommendation 2: 

Sheehan Disability Tool http://health.utah.gov/prescription/pdf/guidelines/SheehanDisabilityScale.pdf



Pain Management Evaluation Tool http://health.utah.gov/prescription/pdf/guidelines/PainManagementWorksheet.pdf

3. The health care provider should screen for risk of abuse or addiction before initiating opioid treatment. 3.1 Use a screening tool to assess the patient’s risk of misuse prior to prescribing an opioid medication for chronic pain.6 A number of screening tools have been developed for assessing a patient’s risk of misuse of medications. The screening tools are intended to assist the health care provider in determining whether opioid treatment is appropriate and in determining the level of monitoring appropriate for the patient’s level of risk.

Oklahoma D.O. PAGE 18

3.2 Consider performing drug screening before initiating long term opioid treatment for chronic pain. Drug testing can identify problems, such as use of undisclosed medications, non-use of reported medications (i.e., potential diversion), undisclosed use of alcohol, or the use of illicit substances, not identified without testing. Health care providers should use a urine drug screen or another laboratory test that can detect the presence of illegal drugs, unreported prescription medications, and/or unreported alcohol use. It is recommended that drug testing be strongly considered and conducted, especially when other factors suggest caution. When screening is limited to situations when there is suspicion of substance misuse, some opportunities may be missed. In one study, testing results upon first admission to a pain clinic did not correlate with reported medication use for nearly one-fourth of patients. Most discrepancies involved substances not reported by the patient; a small minority reported taking medications that were not found on testing.18 6

Oklahoma D.O. | January 2014

A positive drug screen indicates the need for caution, but does not preclude opioid use for the treatment of pain. However, consideration should be given to referral for substance abuse counseling and/or a pain management specialist. If an opioid medication is subsequently prescribed, the patient should be more carefully monitored and the conditions under which opioids are being prescribed should be well documented in the treatment plan. (See Recommendations 5, 6, 8, 12.) Inexpensive immunoassays can be performed in the office. These tests can rapidly determine if opioids are present but they do not identify specific substances. When necessary, specific substances can be identified by ordering confirmatory laboratory testing. However, in many cases, candidly going over the results of the initial in-office test with the patient can eliminate the need for confirmatory testing. It is extremely important to keep in mind that immunoassays have both false-positive and false-negative results. Certain over-the-counter medications may cause a positive result. The prescriber should consider confirmatory gas chromatography or mass spectrometry testing or consultation with a certified Medical Review Officer if drug test results are unclear or confirmation is clinically necessary.9 Tools to accompany Recommendation 3: 

Urine Drug Testing Devices http://health.utah.gov/prescription/pdf/guidelines/CLIADrugTestlist.pdf



Current Opioid Misuse Measure http://health.utah.gov/prescription/tools.html (see Tools to Screen for Risk of Complications on website)



SOAPP-R http://health.utah.gov/prescription/tools.html (see Tools to Screen for Risk of Complications on website)



Opioid Risk Tool http://health.utah.gov/prescription/pdf/guidelines/ORTwithout_scoring.pdf



Signs of Substance Misuse http://health.utah.gov/prescription/pdf/guidelines/signs_substance_misuse.pdf



Checklist for Adverse Effects, Function, and Opioid Dependence http://health.utah.gov/prescription/pdf/guidelines/checklist%20for%20adverse%20effects.pdf

4. Prior to the initial prescribing of opioid medications, health care providers should query the Oklahoma Prescription Monitoring Program (PMP). Most patients who request treatment for pain are legitimately seeking relief of pain. However, subsets of patients seeking treatment for pain are seeking drugs for recreational use, to support an established addiction, or for profit. Information about past patterns of controlled substance prescriptions filled by the patient, such as obtaining medications from multiple providers or obtaining concurrent prescriptions, can alert the provider to potential problems.



Oklahoma Prescription Monitoring Program http://www.ok.gov/obndd/Prescription_Monitoring_Program/

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PAGE 19

Tools to accompany Recommendation 4:

Oklahoma D.O.

The Oklahoma Bureau of Narcotics and Dangerous Drugs Control (OBNDDC) maintains the Oklahoma Prescription Monitoring Program, a real time, searchable database of all controlled substance prescriptions filled in the state. The PMP is used to track and collect data on the dispensing of Schedule II-V drugs by all retail, institutional, and outpatient hospital pharmacies, and in-state/out-of-state mail order pharmacies. Access to the data is provided to authorized individuals and used to identify potential cases of drug over-utilization, misuse, and potential abuse of controlled substances throughout the state. This database is accessible online to all controlled substance prescribers.

5. When opioids are used for the treatment of chronic pain, a written treatment plan should be established that includes measurable goals for reduction of pain and improvement of function. One health care provider should coordinate a patient’s comprehensive pain care plan and provide all opioid prescriptions required for the plan. 5.1 The treatment plan should be tailored to the patient’s circumstances and the characteristics and pathophysiology of the pain. The pathophysiology helps to predict whether opioid medication is likely to help reduce pain or to improve function, and should be considered when establishing treatment goals. Non-opioid treatment modalities should be included in the treatment plan, whenever possible, to maximize the likelihood of achieving treatment goals. 5.2 Goals for the treatment of chronic pain should be measurable and should include improved function and quality of life as well as improved control of pain.6,9,14 For most chronic pain conditions, complete elimination of pain is an unreasonable goal. Goals for treatment of chronic pain should include improvement in the tolerability of pain and function.15 The clinician should counsel the patient on reasonable expectations for treatment outcomes so that agreement is achieved on the goals of addressing pain, function, and quality of life. The pathophysiologic basis of the pain can help establish a prognosis for future improvement (or worsening) in function and pain and should influence the goals of treatment. Goals for functional improvement and measures to track progress against those goals should be established and documented to serve as a basis of evaluating treatment outcomes.6,14 These include: 

Objective physical findings obtained by the examining health care provider (e.g., improved strength, range of motion, aerobic capacity);



Functional status at work (e.g., increase in physical output, endurance, or ability to perform job functions); and



Functional status at home (e.g., increased ability to perform instrumental activities of daily living, and frequency and intensity of conditioning).

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Targets for improved quality of life should also be identified and documented to serve as a basis for evaluating treatment outcomes. These may include: 

Patient rating of quality of life on a measurement scale;



Psychosocial status (e.g., increased social engagement or decreased emotional distress);



Familial status (e.g., improved relationships with, or decreased burden, on family members); and



Physical status (e.g., increased ability to exercise, perform chores, or participate in hobbies).

Health care providers should consider cultural differences in assessing function, quality of life, and pain intensity (see http://prc.coh.org/culture.asp for examples). These measures of improvement could be reported by the patient, family members, and/or the employer. Permission to discuss the patient’s condition with these persons should have been previously obtained and documented. 5.3 Treatment goals should be developed jointly by the patient and health care provider.15 Engage patients in their own health care. Health care providers have observed that when patients assume a significant portion of the responsibility for their rehabilitation they are more likely to improve and that when they participate in goal setting they are more likely to achieve the goals. As with any other chronic illness (such as diabetes or heart disease), the health care provider should focus not just on pain control, but also on treating the patient’s underlying diseases and encouraging them to engage in ownership of their own health. 8

Oklahoma D.O. | January 2014

Tools to accompany Recommendation 5: 

Pain Management Evaluation Tool http://health.utah.gov/prescription/pdf/guidelines/PainManagementWorksheet.pdf



Patient Pain and Medication Tracking Chart http://health.utah.gov/prescription/pdf/guidelines/PatientPain-FunctionTracking.pdf



Sheehan Disability Scale http://health.utah.gov/prescription/pdf/guidelines/SheehanDisabilityScale.pdf



Brief Pain Inventory Form http://health.utah.gov/prescription/pdf/guidelines/BriefPainInvNPEC.pdf



Sample Treatment Plan for Prescription Opioids http://health.utah.gov/prescription/pdf/guidelines/treatment_plan.pdf



Cultural considerations in assessing function, quality of life, and pain intensity http://prc.coh.org/culture.asp

6. The patient should be informed of the risks, benefits, and terms for continuation of opioid treatment, ideally using a written and signed treatment agreement.13 6.1 Patients should be informed not to expect complete relief from pain. The excitement and euphoria of initial pain relief that may occur with a potent opioid can lead the patient to expect long-term complete pain relief. Without careful guidance, this may lead the patient to disappointment and to seek excessive doses of opioids. The patient should be counseled about the appropriate use of opioid medications, possible adverse effects, and the risks of developing tolerance, physical and/or psychological dependence, and withdrawal symptoms.9,19 Adverse effects can include opioid-induced hyperalgesia, allodynia, abnormal pain sensitivity, and depression.6,9,20 Sedation and cognitive impairment may occur when patients are taking opioid medications. Therefore, discuss with patients the need for caution in operating motor vehicles or equipment or performing other tasks where impairment would put them or others at risk.11 Ensure the patient does not have any absolute contraindications, and review risks and benefits related to any relative contraindications with the patient. Absolute contraindications for opioid prescribing: Allergy to an opioid agent (may be addressed by using an alternative agent);



Co-administration of a drug capable of inducing life-threatening drug-drug interaction; and



Active diversion of controlled substances (providing medication to someone for whom it was not prescribed).

More detail about absolute contraindications is contained in the Guidelines Tools section.



Snoring heavily and cannot be awakened;



Periods of ataxic (irregular) or other sleep disordered breathing;



Trouble breathing;

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PAGE 21

Consider co-prescribing naloxone for high risk patients, and providing training to family/caregivers to reverse potential life-threatening depression of the respiratory and central nervous system. Educate patients and family/caregivers about the danger signs of respiratory depression. Everyone in the household should know to summon medical help immediately if a person demonstrates any of the following signs while on opioids:

Oklahoma D.O.



Exhibiting extreme drowsiness and slow breathing;



Slow, shallow breathing with little chest movement;



Increased or decreased heartbeat; and



Feeling faint, very dizzy, confused or has heart palpitations.

6.2 The patient and, when applicable, the family or caregiver should be involved in the education process.14 Educational material should be provided in written form and discussed in person with the patient and, when applicable, the family or caregiver.14 Educating the family or caregiver about the signs of opioid overdose may help detect problems before they lead to a serious complication. It is important to act within the constraints of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA regulates the conditions under which information about the patient can be disclosed to others, such as family members, and under what conditions discussions about the patient with others are allowed. 6.3 The treatment plan, which defines the responsibilities of both the patient and health care provider, should be documented.6,9,13,14,15 Patient responsibilities include properly obtaining, filling, and using prescriptions, and adherence to the treatment plan. Patient responsibilities also include instructions to keep a pain diary, a diary or log of daily activities and accomplishments, and/or instructions on how and when to give feedback to the prescriber.14 The prescribing health care provider may consider requiring that the treatment plan be documented in the form of a treatment agreement signed by the patient. Patients should be encouraged to store opioid medications in a secure location to keep the medication away from others who should not have access to them. 6.4 The treatment plan should contain goals of treatment, guidelines for prescription refills, agreement to submit to urine or serum screening upon request, and reasons for possible discontinuation of drug therapy.9,13,14,15,17 The treatment plan (sometimes referred to as a treatment agreement) should contain the items developed jointly by the patient and health care provider, such as follow-up appointments, the pharmacy and health care provider to be used, as well as any non-negotiable demands or limitations the health care provider wishes to make, such as the prohibition of sharing or trading the medication or getting refills early. Specific grounds for immediate termination of the agreement and cessation of prescribing may also be specified, such as forgery or selling of prescriptions or medications or obtaining them from multiple providers as documented by Oklahoma’s Prescription Monitoring Program.14,20

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Optional inclusions in the agreement: 

Pill counts may be required as a means to gauge proper medication use;14,19



Prohibition of use with alcohol or certain other medications;14



Documentation of counseling regarding driving or operating heavy machinery; and 6,14



Specific frequencies of urine testing.

Ideally, the patient should be receiving prescriptions from one prescriber only and filling those prescriptions at one pharmacy only.14,17,19 It is not necessary to include specific consequences for specific non-compliant behaviors, but it should be documented in the treatment agreement that continuing failure by the patient to adhere to the treatment plan will result in escalating consequences, up to and including termination of the clinician-patient relationship and of opioid prescribing by that clinician. 6.5 Discuss involvement of family members in the patient’s care and request that the patient give written permission to talk with family members about the patient’s care. 10

Oklahoma D.O. | January 2014

This is best done before starting to treat the patient because it can be more difficult to obtain consent after an issue occurs. Prior to initiating treatment with opioids, the health care provider may want to consider a family conference to help assess the patient’s integrity.19 Consultation with others, however, must be done within the constraints of HIPAA, as noted above. (See Recommendation 6.2.) Tools to accompany Recommendation 6: 

Absolute Contraindications to Opioid Prescribing http://health.utah.gov/prescription/pdf/guidelines/absolute_contraindications.pdf



Sample Treatment Plan for Prescribing Opioids http://health.utah.gov/prescription/pdf/guidelines/treatment_plan.pdf



Signs of Substance Misuse http://health.utah.gov/prescription/pdf/guidelines/signs_substance_misuse.pdf



Guidance on HIPAA http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/provider_ffg.pdf



Prescription Drug Overdose in Oklahoma Brochure http://www.ok.gov/health2/documents/DrugOverDoseBrochure_2013.pdf

Initiating, Monitoring, and Discontinuing Opioid Treatment 7. Opioids should be initiated as a short-term trial to assess the effects of opioid treatment on pain intensity, function, and quality of life. In most instances, the trial should begin with a short-acting opioid medication. 7.1 The health care provider should clearly explain to the patient that initiation of opioid treatment is not a commitment to long-term opioid treatment and that treatment will be stopped if the trial is determined to be unsuccessful. The trial should be for a specific time period with pre-determined evaluation points. The decision to continue opioid medication treatment beyond the trial period should be based on the balance between benefits, including function and quality of life, and adverse effects experienced. Criteria for cessation should be considered before treatment begins. Refer to Recommendation 11 for more information on discontinuation of treatment. 7.2 Short-acting opioid medications are, in general, safer and easier to titrate to an effective dose. If the treatment trial proves successful in achieving the goals established in the treatment plan, the health care provider may consider switching the patient to a long-acting or sustained-release formulation. The patient’s individual situation should influence whether the patient is switched from a short-acting medication. Treatment with a long-acting opioid medication before a trial using a short-acting medication has been performed is an option that should be prescribed only by those with considerable expertise in chronic pain management.

8. Regular visits for evaluation of progress toward goals should be scheduled during the period when the dose of opioids is being adjusted (titration period). During the titration period, and until the patient is clinically stable and judged to be compliant with therapy, it is recommended that the health care provider check the Oklahoma PMP more frequently.14 Oklahoma D.O. | January 2014

PAGE 23

Titration Phase of Opioid Treatment

Oklahoma D.O.

Tools to accompany Recommendation 7:  Dosing Guidelines http://health.utah.gov/prescription/pdf/guidelines/dosing_guidelines.pdf  Current Opioid Misuse Measure (COMM) http://health.utah.gov/prescription/tools.html (see Tools to Screen for Risk of Complications on website)

8.1 Face-to-face follow-up visits should occur at least every 2-4 weeks during the titration period. More frequent follow-up visits may be advisable and caution should be used when prescribing an opioid medication if the patient has a known addiction problem, suspected drug-behavior problems, or co-existing psychiatric or medical problems. Frequency of visits should also be based on risk stratification (e.g., as determined by a screening tool) and the clinician’s judgment (taking into account the volume of the drug being prescribed and how likely it is to be abused).15 8.2 When pain and function have not sufficiently improved on a current opioid dose, a trial of a slightly higher dose could be considered.14,15 The rate at which the dosing is increased should balance the risk of leaving the patient in a painful state longer than necessary by increasing too slowly with the risk of causing harm, including fatal overdose, by increasing too fast. Ideally, only one drug at a time should be titrated in an opioid-naïve patient.14 Age, health, and severity of pain should be taken into consideration when deciding on increments and rates of titration. Particular caution should be used in titrating dosing of methadone. Evidence and other guidelines are not in agreement regarding the risks and benefits of high daily doses of opioid measured in morphine milligram equivalents (MMEs). It is likely that the risk-benefit ratio is less favorable at higher doses. Clinical vigilance is needed at all dosage levels of opioids, but is even more important at higher doses. Health care providers who are not experienced in prescribing high doses of opioids should consider either referring the patient or obtaining a consultation from a qualified provider for patients receiving high dosages. No clear threshold for a high dose has been established based on evidence. The Washington State guidelines suggest a threshold of 120 MME per day. It is important to increase clinical vigilance at doses exceeding 120 MME per day. Patients receiving 100 MME or more per day had a 9-fold increase in overdose risk. Most overdoses were medically serious, 12% were fatal.9 During titration, all patients should be seen frequently until dosing requirements have stabilized. Patients should be instructed to use medication only as directed, that is, not to change doses or frequency of administration without specific instructions from the health care provider. 8.3 During the titration period, and until the patient is clinically stable and judged to be compliant with therapy, it is recommended that the health care provider check the Oklahoma Prescription Monitoring Program more frequently, such as monthly or quarterly.

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Tools to accompany Recommendation 8: 

Dosing Guidelines http://health.utah.gov/prescription/pdf/guidelines/dosing_guidelines.pdf



Electronic MME Dosing Calculator http://agencymeddirectors.wa.gov/mobile.html



Prescription Monitoring Program http://www.ok.gov/obndd/Prescription_Monitoring_Program/

Maintenance of Opioid Treatment 9. Once a stable dose has been established (maintenance period), regular monitoring should be conducted at face-to-face visits during which treatment goals, analgesia, activity, adverse effects, and aberrant behaviors are monitored. The Oklahoma PMP should be queried at least once per year for patients receiving opioid treatment for chronic pain.13,15 9.1 The health care provider is advised to consider baseline drug testing at the initiation of opioid treatment, compliance monitoring one to three months later, and random monitoring every 6-12 months. In the event of unexpected drug screens or suspicious patient behavior, additional monitoring can be performed. Health care 12

Oklahoma D.O. | January 2014

providers may consider each of the following four areas of concern at each visit: Analgesia, Activity, Adverse effects, and Aberrant behavior. These assessments can be remembered as the “four A’s”: 21 

Analgesia: inquire about level of pain (current, recent, trends, etc.)



Activity: assess the patient’s function and overall quality of life



Adverse events: determine whether the patient is having medication side effects



Aberrant behavior: evaluate for possible drug abuse-related behavior

9.2 During the maintenance period, the Oklahoma Prescription Monitoring Program should be checked at least annually. After the titration period is complete and the maintenance period is underway, the frequency of checks of the Oklahoma PMP can be based on clinical judgment, but should be done no less than annually. The Oklahoma PMP should be checked more often for high risk patients and patients exhibiting aberrant behavior. 9.3 Continuation or modification of treatment should depend on the health care provider’s evaluation of progress towards stated treatment goals.13 Treatment goals include reduction in a patient’s pain scores and improved physical, psychological, and social function. If patient compliance with agreed-upon activity levels, are not being achieved despite medication adjustments, the health care provider should re-evaluate the appropriateness of continued treatment with the current medications.9,17 A frequent need for dose adjustments after a reasonable time interval of titration is an indication to re-evaluate the underlying condition and consider the possibility the patient has developed opioid hyperalgesia, substantial tolerance, or psychological/physical dependence. 9.4 Adjustments to previously stable maintenance treatment may be considered if the patient develops tolerance, a new pain-producing medical condition arises or an existing one worsens, or if a new adverse effect emerges or becomes more clinically significant.14 Options for adjustment include reducing the medication or rotating opioid medications. If it is documented that the patient is compliant with agreed-upon recommendations such as exercise, working, etc., the addition of supplemental short-acting medications for control of break-through pain (e.g., as related to an increase in activity, end-of-dose pain, weather-related pain exacerbation, or specific medical conditions) can be considered as well. If patients do not achieve effective pain relief with one opioid, rotation to another frequently produces greater success.22 If rotating among different opioid medications, refer to a standard dosing equivalence table, taking into account the current drug’s half-life and potency.

9.5 Dosing changes should generally be made during a clinic visit.14

Tapering an opioid medication with or without the goal of discontinuation may be performed as described below (Recommendation 11) or as described in the Strategies for Tapering and Weaning Tool.

Oklahoma D.O. | January 2014

PAGE 25

If the patient’s underlying, pain-producing, chronic medical condition improves, it is expected that the health care provider will begin tapering the patient off the opioid medication. (See Recommendation 11 for guidelines on discontinuation.)

Oklahoma D.O.

If the patient’s situation has changed permanently and consideration is given to the increased risk of adverse events, it is reasonable to consider an ongoing increase in maintenance dosing. In general, if the patient’s underlying medical condition is chronic and unchanging, and if opioid-associated problems (hyperalgesia, substantial tolerance, important adverse effects) have not developed, it is recommended that the effective dose achieved through titration not be lowered once the patient has reached a plateau of adequate pain relief and functional level.14

Tools to accompany Recommendation 9: 

Checklist for Adverse Effects, Function, and Opioid Dependence http://health.utah.gov/prescription/pdf/guidelines/checklist%20for%20adverse%20effects.pdf



Signs of Substance Misuse http://health.utah.gov/prescription/pdf/guidelines/signs_substance_misuse.pdf



Pain Management Evaluation Tool http://health.utah.gov/prescription/pdf/guidelines/PainManagementWorksheet.pdf



Dosing Guidelines http://health.utah.gov/prescription/pdf/guidelines/dosing_guidelines.pdf



Strategies for Tapering and Weaning http://health.utah.gov/prescription/pdf/guidelines/Strategies_tapering_weaning.pdf

Evaluating the Opioid Treatment Trial 10. Continuing opioid treatment should be a deliberate decision that takes into consideration the risks and benefits of chronic opioid treatment for that patient. Patients and health care providers should periodically reassess the need for continued opioid treatment, weaning whenever possible, as part of the comprehensive pain care plan. A second opinion or consultation may be useful in making that decision. The health care provider should clearly explain to the patient that initiation of opioid treatment is not a commitment to long-term opioid treatment and that treatment will be stopped if the trial is determined to be unsuccessful. The trial should be for a specific time period with pre-determined evaluation points. The decision to continue opioid treatment beyond the trial period should be based on the balance between benefits, including function and quality of life, and adverse effects experienced. A second opinion or consult may be useful in making the decision to continue or discontinue opioids after the treatment trial.

Discontinuing Opioid Treatment 11. Opioid treatment should be discontinued if adverse effects outweigh benefits, or if aberrant, dangerous, or illegal behaviors are demonstrated.9

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11.1 Discontinuation of opioid treatment is recommended if any of the following occurs: 

Dangerous or illegal behaviors are identified;



Patient claims or exhibits a lack of effectiveness;



Pain problem resolves;



Patient expresses a desire to discontinue therapy; and



Opioid treatment appears to be causing harm to the patient, particularly if harm exceeds benefit.14

The decision to discontinue opioid treatment should ideally be made jointly with the patient and, if appropriate, the family/caregiver.17 This decision should include careful consideration of the outcomes of ongoing monitoring. 11.2 When possible, offer to assist patients in safely discontinuing medications, even if they have withdrawn from treatment or been discharged for agreement violations.14 The goal is to taper all patients off opioid medications safely. If the patient is discharged, the health care provider is obliged to offer continued monitoring for 30 days post-discharge. Possible complications of opioid 14

Oklahoma D.O. | January 2014

withdrawal should be taken into consideration when discontinuing or tapering opioid medications. Tools to accompany Recommendation 11: 

Strategies for Tapering and Weaning http://health.utah.gov/prescription/pdf/guidelines/Strategies_tapering_weaning.pdf

Documentation and Medical Records 12. Health care providers treating chronic pain patients with opioids should maintain records, in accordance with state and federal law, documenting patient evaluation, treatment plan, discussion of risks and benefits, informed consent, treatments prescribed, results of treatment, and any aberrant behavior observed. 9,13,14,15,17 12.1 A written treatment plan should document objectives that will be used to evaluate treatment success.9,13,14,15,17 12.2 Opioid prescriptions should be written on tamper-resistant prescription paper to help reduce the likelihood of prescription fraud or misuse.15 To reduce the chance of tampering with the prescription, write legibly, and keep a copy.15 12.3 Assessment of treatment effectiveness should be documented in the medical record.9,13,15 Both the underlying medical condition responsible for the pain, if known, and other medical conditions that may affect the efficacy of treatment or risks of adverse events should be assessed and documented at every visit. Health care providers should consider utilizing a standardized approach such as “The Four A’s” or “The SAFE Tool” for medical documentation. The Four A’s considers four areas of concern: Analgesia, Activity, Adverse effects, and Aberrant behavior.21 The SAFE Tool is a numerical five point scoring system that helps to guide the health care provider toward broader views of treatment options.23 It considers four areas of concern: social functioning (S), analgesia (A), physical function (F), and emotional functioning (E). The Four A’s can be remembered as:    

Analgesia: inquire about level of pain (current, recent, trends, etc.); Activity: assess both the patient’s function and overall quality of life; Adverse events: determine whether the patient is having medication side effects; and Aberrant behavior: regularly evaluate for possible drug abuse-related behavior.

The SAFE Tool can be remembered as: Social functioning: inquire about family and employment relationships; Analgesia: inquire about level of pain (current, recent, trends, etc.); Physical functioning: inquire about how well the patient is meeting goals; and Emotional functioning: ask about changes in the patient’s mental health status.

12.4 Adherence to the treatment plan, including any evidence of aberrant behavior, should be documented in the medical record.14 Specific components of the treatment plan for which adherence should be assessed include: Use of opioid analgesics; and



Follow-up referrals, tests, and other therapies.

Health care providers are encouraged to make use of resources designed to assist them in managing the care of patients with aberrant behavior. Serious non-adherence issues (e.g., illegal, criminal, or dangerous behaviors, including altering of prescriptions) may also warrant immediate discontinuation of opioid treatment. Oklahoma D.O. | January 2014

PAGE 27



Oklahoma D.O.

   

Tools to accompany Recommendation 12: 

Checklist for Adverse Effects, Function, and Opioid Dependence http://health.utah.gov/prescription/pdf/guidelines/checklist%20for%20adverse%20effects.pdf



Signs of Substance Misuse http://health.utah.gov/prescription/pdf/guidelines/signs_substance_misuse.pdf



Federal Laws on Prescribing Controlled Substances (21 CFR 1306 et. seq.) http://www.deadiversion.usdoj.gov/21cfr/cfr/



Osteopathic Rules on Prescribing for Intractable Pain (OAC 510:5-9-1 et. seq.) http://www.ok.gov/osboe/documents/RULES.pdf



Medical Board Rules on Prescribing for Intractable Pain (OAC 435:10-7-11 et. seq.) http://www.okmedicalboard.org/download/457/MDRULES.pdf

Consultation and Management of Complex Patients 13. Health care providers should consider consultation for patients with complex pain conditions, serious co-morbidities and mental illness, a history or evidence of current drug addiction or abuse, or when the provider is not confident of his or her ability to manage the treatment.9,13 13.1 Prescribers may wish to consider referring patients if any of the following conditions or situations are present, or if other concerns arise during treatment: 

The patient has a complex pain condition and the clinician wishes verification of diagnosis;



The patient has significant co-morbidities, including psychiatric illness;



The patient is at high risk of aberrant behavior or addiction; or



The clinician suspects the development of significant tolerance, particularly at higher doses.

The main goal of a consultation is for the prescribing clinician to receive recommendations for ongoing treatment. 13.2 Patients with a history of addiction or substance use disorder or who have positive drug screens indicative of a problem should be closely monitored (e.g., more frequent random drug screens, random pill counts) or considered for referral to an addiction specialist for evaluation of recurrent risk and for assistance with treatment.9,13,14

Oklahoma D.O. PAGE 28

Although this is a desirable approach, it is recognized that following this recommendation may not be feasible in parts of Oklahoma where there is a shortage of readily available addiction specialists. 13.3 Pain patients addicted to medications/drugs should be referred to a pain management and/or mental health/substance use disorder specialist, if available, for recommendations on the treatment plan and assistance in management. The health care provider may consider prescribing opioid medications for pain even if the patient has a selfreported or documented previous opioid abuse problem, as long as monitoring is performed during the titration and maintenance phase. 13.4 Patients with a coexisting psychiatric disorder should receive ongoing mental health support and treatment while receiving an opioid medication for pain control. Management of patients with a coexisting psychiatric condition may require extra care, monitoring, or documentation.17,19 Consultation can be obtained to assist in formulating the treatment plan and establishing a 16

Oklahoma D.O. | January 2014

plan for coordinated care of both the chronic pain and psychiatric condition(s). Tools to accompany Recommendation 13: 

Strategies for Tapering and Weaning http://health.utah.gov/prescription/pdf/guidelines/Strategies_tapering_weaning.pdf

14. Health care providers should generally not provide replacement prescriptions for opioids that have been lost, stolen, or destroyed. Patients misusing controlled substances frequently report their opioid medications as having been lost or stolen. Pain specialists routinely stipulate in pain agreements with patients that lost or stolen controlled substances will not be replaced. Most written agreements between chronic pain patients and pain management physicians, including the Health Resources and Services Administration (HRSA) toolkit sample pain agreement, state that prescriptions for opioids will not be replaced.10 The diversion of prescribed opioids is common. One study looked at completed patient surveys and determined that 45% of respondents reported some form of drug diversion at least once. Stolen medication was the most prevalent method of drug diversion, and 30% of respondents reported at least one incident of stolen medication.11 Another survey study found that among persons 12 years and older who abused opioid pain medications (2009-2010), 71.2% came from friends or relatives; 55% were given to the abuser, while 11.4% were purchased, and 4.8% were stolen.12,13 15. The administration of intravenous and intramuscular opioids for the relief of exacerbations of chronic pain is discouraged, except in special circumstances. Parenteral opioids should be generally avoided for the treatment of chronic pain because of their short duration and potential for addictive euphoria. For chronic pain, oral opioids are superior to parenteral opioids in duration of action and provide a gradual decrease in the level of pain control. When there is evidence or reasonable suspicion of an acute pathological process causing the acute exacerbation of chronic pain, parenteral opioids may be appropriate. Tools to accompany Recommendation 15: 

Dosing Guidelines http://health.utah.gov/prescription/pdf/guidelines/dosing_guidelines.pdf



Current Opioid Misuse Measure (COMM) http://health.utah.gov/prescription/tools.html (see Tools to Screen for Risk of Complications)

Methadone and Extended Release/Long-Acting Opioids

16.1 The prescription use of methadone remains controversial due to concerns about its efficacy and safety. During the past two decades methadone-related death rates increased in Oklahoma and the U.S. From 20072011, methadone was listed in the cause of death in 21% of prescription drug-related unintentional poisoning deaths in Oklahoma.1

Oklahoma D.O. | January 2014

PAGE 29

The half-life of methadone is long and unpredictable, increasing the risk of inadvertent overdose. The peak respiratory depressant effect of methadone occurs later and lasts longer after treatment initiation or dosage change than does the peak analgesic effect. Conversion tables that have been established to assist with converting a patient from another opioid medication to methadone are considered by many experts to be unreliable.

Oklahoma D.O.

16. Long-acting opioids are associated with an increased risk of overdose death, and should only be prescribed by health care providers familiar with their indications, risks, and need for careful monitoring.

Methadone metabolism is complicated and varies among individuals. Methadone interacts with several other medications that can alter its metabolism, changing the effects of a given dose on pain and on respiratory depression. Potential for interactions should be considered before starting methadone in a patient taking other medications, and before starting any medication in a patient taking methadone. Methadone can prolong the rate-corrected QT interval (QTc), increase the risk of Torsades de Pointe, and sudden cardiac death. Caution should be used in prescribing methadone to any patient at risk for prolonged QTc interval, including those with structural cardiac disease, cardiac arrhythmias or cardiac conduction abnormalities and in patients taking another medication associated with QTc interval prolongation.24 An online reference of such medications is available at: http://www.azcert.org/medical-pros/drug-lists/drug-lists.cfm. Health care providers should consider obtaining an electrocardiogram (ECG) to measure the QTc interval in patients treated with methadone, especially at higher doses. A recently published consensus guideline recommended that an ECG be performed before prescribing methadone, within the first 30 days, and annually. Additional ECG examinations were recommended if the methadone dose exceeds 100 mg per day or if a patient on methadone has unexplained syncope or seizure. Guidance was provided for actions to be taken at two levels of QTc prolongation (450-500 ms and greater than 500 ms).25 Methadone and other opioids have been associated with worsening obstructive sleep apnea and new onset of central sleep apnea. Clinicians should question patients about symptoms and signs of sleep apnea and consider obtaining a sleep study in patients treated with opioids if they develop any signs of sleep-disordered breathing or respiratory depression. This is particularly important for patients receiving higher doses of opioid medications. In a recent study, 92% of patients on opioid doses at or above 200 MMEs had developed ataxic or irregular breathing.25 16.2 If extended release/long-acting opioids are prescribed, consideration should be given to the increased risk of overdose with these medications. Prescribers should consider the current risk evaluation and implement mitigation strategies and close monitoring to reduce the possibility of adverse events. Tools to accompany Recommendation 16: ď&#x201A;ˇ

Dosing Guidelines http://health.utah.gov/prescription/pdf/guidelines/dosing_guidelines.pdf

ď&#x201A;ˇ

The Role of Methadone in the Management of Chronic Non-Malignant Pain http://health.utah.gov/prescription/pdf/guidelines/role_of_methadone.pdf

ď&#x201A;ˇ

Electronic MME Dosing Calculator http://agencymeddirectors.wa.gov/mobile.html

Oklahoma D.O. PAGE 30

Education of Chronic Pain Patients on Using Opioids 17. When opioids are prescribed for treatment of chronic pain, the patient should be counseled to store the medications securely and never to share with others. In order to prevent nonmedical use of the medications, it is also recommended that patients dispose of medications when the pain has resolved. It is important that patients understand the need to store medications securely. Health care providers should encourage patients to keep medications in a locked environment rather than in easily accessible locations, such as the bathroom or kitchen cabinet, where they are accessible to unsuspecting children, curious teenagers, and can be a target for theft. Tell the patient that if they have leftover medications after they have recovered, they should dispose of their medications immediately to help protect them from being a target for theft as well as protect others from getting into the medications. 18

Oklahoma D.O. | January 2014

Tools to accompany Recommendation 17:  United States Food and Drug Administration (FDA) Guidelines on Proper Disposal of Prescription Drugs http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/Under standingOver-the-CounterMedicines/ucm107163.pdf 

Oklahoma Bureau of Narcotics and Dangerous Drugs Take Back Container Locations http://www.ok.gov/obndd/documents/TakeBackBoxes.pdf

Oklahoma D.O. PAGE 31

Oklahoma D.O. | January 2014

Guidelines Tools Tools to use in evaluation and monitoring:      

Pain Management Evaluation Tool http://health.utah.gov/prescription/pdf/guidelines/PainManagementWorksheet.pdf Patient Pain and Medication Tracking http://health.utah.gov/prescription/pdf/guidelines/PatientPain-FunctionTracking.pdf Sheehan Disability Scale http://health.utah.gov/prescription/pdf/guidelines/SheehanDisabilityScale.pdf Brief Pain Inventory Form http://health.utah.gov/prescription/pdf/guidelines/BriefPainInvNPEC.pdf Treatment Plan for Prescribing http://health.utah.gov/prescription/pdf/guidelines/treatment_plan.pdf SF-12 http://health.utah.gov/prescription/pdf/guidelines/SF-12v2Standard-Sample.pdf

Tools to screen for risk of complications:       

Oklahoma Prescription Monitoring Program http://www.ok.gov/obndd/Prescription_Monitoring_Program/ Current Opioid Misuse Measure (COMM) http://health.utah.gov/prescription/tools.html SOAPP-R http://health.utah.gov/prescription/tools.html Opioid Risk Tool http://health.utah.gov/prescription/pdf/guidelines/ORTwithout_scoring.pdf Urine Drug Testing Devices http://health.utah.gov/prescription/pdf/guidelines/CLIADrugTestlist.pdf Signs of Substance Misuse http://health.utah.gov/prescription/pdf/guidelines/signs_substance_misuse.pdf Checklist for Adverse Effects, Function, and Opioid Dependence http://health.utah.gov/prescription/pdf/guidelines/checklist%20for%20adverse%20effects.pdf

Informational tools:  

Oklahoma D.O. PAGE 32

    

United States Food and Drug Administration (FDA) Guidelines on Proper Disposal of Prescription Drugs http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/Understandin gOver-the-CounterMedicines/ucm107163.pdf Non-opioid Pain Management Tool http://health.utah.gov/prescription/tools.html Absolute Contraindications to Opioid Prescribing http://health.utah.gov/prescription/pdf/guidelines/absolute_contraindications.pdf Strategies for Tapering and Weaning http://health.utah.gov/prescription/pdf/guidelines/Strategies_tapering_weaning.pdf Information for Patients-Opioid Analgesics for Non-cancer Pain http://health.utah.gov/prescription/pdf/guidelines/Information_for_patients.Opioid_analgesics_for_noncancer_pain.pdf The Role of Methadone in the Management of Chronic Non-Malignant Pain http://health.utah.gov/prescription/pdf/guidelines/role_of_methadone.pdf Dosing Guidelines http://health.utah.gov/prescription/pdf/guidelines/dosing_guidelines.pdf 20

Oklahoma D.O. | January 2014

     

Prescription Drug Overdose in Oklahoma Brochure http://www.ok.gov/health2/documents/DrugOverDoseBrochure_2013.pdf Oklahoma Bureau of Narcotics and Dangerous Drugs Take Back Container Locations http://www.ok.gov/obndd/documents/TakeBackBoxes.pdf Electronic MME Dosing Calculator http://agencymeddirectors.wa.gov/mobile.html Federal Laws on Prescribing Controlled Substances (21 CFR 1306 et. seq.) http://www.deadiversion.usdoj.gov/21cfr/cfr/ Osteopathic Rules on Prescribing for Intractable Pain (OAC 510:5-9-1 et. seq.) http://www.ok.gov/osboe/documents/RULES.pdf Medical Board Rules on Prescribing for Intractable Pain (OAC 435:10-7-11 et. seq.) http://www.okmedicalboard.org/download/457/MDRULES.pdf

Oklahoma D.O. PAGE 33

Oklahoma D.O. | January 2014

Opioid Prescribing Guidelines for Oklahoma Workgroup Members Mark Brandenburg, M.D., FACEP, FAAEM, Emergency Physician, Oklahoma Injury Prevention Advisory Committee (Committee Chair) Pam Archer, M.P.H., Oklahoma State Department of Health Deborah Bruce, J.D., Oklahoma State Board of Osteopathic Examiners Max Burchett Jr., Pharm.D., Indian Health Service Laura Clarkson, R.N., CARN, Oklahoma Board of Nursing Patti Davis, Oklahoma Hospital Association John Foust, Pharm.D., D.Ph., Oklahoma State Board of Pharmacy Eric Frische, M.D., Oklahoma Board of Medical Licensure and Supervision Cecilia Guthrie, M.D., FAAP, Oklahoma Chapter of American College of Emergency Physicians LaWanna Halstead, R.N., M.P.H., Oklahoma Hospital Association Jessica Hawkins, Oklahoma Department of Mental Health and Substance Abuse Services Mike Herndon, D.O., Oklahoma Health Care Authority Timothy Hill, Ph.D., M.D., FACEP, Oklahoma Chapter of American College of Emergency Physicians Rafael Justiz, M.D., M.S., DABIPP, FIPP, Oklahoma Society of Interventional Pain Physicians Lyle Kelsey, M.B.A., CMBE, Oklahoma Board of Medical Licensure and Supervision Cathy Kirkpatrick, Oklahoma State Board of Veterinary Medical Examiners Rachel Mack, DNP, APRN, C-NP, Oklahoma City University Kramer School of Nursing Heidi Malling, M.D., University of Oklahoma Health Sciences Center Dan McNeill, PA-C, Ph.D., Physician Assistant Nancy Nesser, Pharm.D., J.D., Oklahoma Health Care Authority Claire Nguyen, M.S., Oklahoma State Department of Health Tracie Patten, Pharm.D., Indian Health Service Laura Petty, D.Ph., Pharmacist Avy Redus, M.S., Oklahoma State Department of Health

Oklahoma D.O. PAGE 34

Layne E. Subera, D.O., FACOFP, Oklahoma State Board Association of Osteopathic Examiners Osteopathic Disclaimer: This document should not be used to establish any standard of care. No legal proceeding, including medical malpractice proceedings or disciplinary hearings, should reference a deviation from any part of this document as constituting a breach of professional conduct. These guidelines are only an educational tool. Clinicians should use their own clinical judgment and not base clinical decisions solely on this document. The recommendations are based on evidence-based research, promising interventions, and expert opinion. Additional research is needed to understand the impact of these interventions on decreasing unintentional drug poisoning and on health care costs. These guidelines should be considered by clinicians, hospitals, administrators, public health entities, and other relevant stakeholders.

Oklahoma D.O. | January 2014

References 1

Oklahoma State Department of Health, Injury Prevention Service. Unintentional Poisoning Fatality Surveillance System. [Data file].

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2012). Webbased Injury Statistics Query and Reporting System (WISQARS). Retrieved from http://webappa.cdc.gov/sasweb/ncipc/dataRestriction_inj.html. Accessed September 23, 2013. 3

Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health. Retrieved from http://oas.samhsa.gov/2k8state/AppB.htm. Accessed September 23, 2013.

Centers for Disease Control and Prevention. (2011). Prescription Painkiller Overdoses in the U.S. Retrieved from http://www.cdc.gov/vitalsigns/painkilleroverdoses/. Accessed September 10, 2013. 5

Utah Department of Health. (2009). Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Retrieved from http://health.utah.gov/prescription/pdf/guidelines/final.04.09opioidGuidlines.pdf. Accessed September 10, 2013. 6

American College of Occupational and Environmental Medicine. (2008). Occupational Medicine Practice Guidelines. Retrieved from http://www.acoem.org/practiceguidelines.aspx. Accessed September 23, 2013. 7

Braden, J.B., Russo, J., Fan, M., Edlund, M.J., Martin, B.C., DeVries, A., & Sullivan, M.D. (2010). Emergency department visits among recipients of chronic opioid therapy. Archives of Internal Medicine, 70(16), 1425-1432. 8

Edlund, M.J., Martin, B.C., DeVries, A., Fan, M., Braden, J.B., & Sullivan, M.D. (2010). Trends in use of opioids for chronic non-cancer pain among individuals with mental health and substance use disorders: the TROUP study. Clinical Journal of Pain, 26(1), 1-8. 9

Washington State - Agency Medical Directors Group. (2010). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy. Retrieved from http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed September 23, 2013. 10

Washington State Health Care Authority. (2009). HRSA Toolkit. Retrieved from http://www.hca.wa.gov/medicaid/pharmacy/pages/toolkit.aspx. Accessed October 23, 2013. 11

Walker, M.J. & Webster, L.R. (2012). Risk factors for drug diversion in a pain clinic patient population. Journal of Opioid Management, 8(6), 351-362. 12

Manchikanti, L., Abdi, S., Atluri, S., Balog, C.C., Benyamin, R.M., Boswell, M.V., . . . Wargo, B.W. (2012). Opioid guidelines 2012: American society of interventional pain physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I â&#x20AC;&#x201C; Evidence assessment pain physician. Pain Physician Journal, 15, S1-S66. United States Department of Veterans Affairs. (2010). VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Retrieved from http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp. Accessed September 24, 2013.

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Substance Abuse and Mental Health Services Administration. (2012). Results from the 2010 National Survey on Drug Use and Health. Retrieved from http://www.samhsa.gov/data/NSDUH/2k10ResultsRev/NSDUHresultsRev2010.htm. Accessed September 24, 2013.

College of Physicians and Surgeons of Ontario. (2000). Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain. Retrieved from http://www.cpsa.ab.ca/Libraries/pro_tpp/MedicalManagementPain.pdf?sfvrsn=0. Accessed September 24, 2013.

World Health Organization. (2013). WHOâ&#x20AC;&#x2122;s Pain Ladder for Adults. Retrieved from http://www.who.int/cancer/palliative/painladder/en/. Accessed October 10, 2013.

Federation of State Medical Boards of the United States, Inc. (2004). Model Policy for the Use of Controlled Substances for the Treatment of Pain. Retrieved from http://www.fsmb.org/pdf/2004_grpol_controlled_substances.pdf. Accessed September 24, 2013.

Berndt, S., Maier, C., & Schutz, H.W. (1993). Polymedication and medication compliance in patients with chronic non-malignant pain. Pain, 52(3), 331-339.

Trescot, A.M., Helm, S., Hansen, H., Benyamin, R., Glaser, S.E., Adlaka, R., . . . Manchikanti, L. (2008). Opioids in the management of chronic non-cancer pain: An update of American society of the interventional pain physiciansâ&#x20AC;&#x2122; (ASIPP) guidelines. Pain Physician, 11, S5-S62. 20

Daniell, H.W. (2008). Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. Journal of Pain, 9 (1), 28-36. 21

Passik, S.D. & Weinreb, H.J. (2000). Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids. Advances in Therapy, 17(2), 70-83.

Quang-Cantagrel, N.D., Wallace, M.S., & Magnuson, S.K. (2000). Opioid substitution to improve the effectiveness of chronic noncancer pain control: A chart review. Anesthesia and Analgesia, 90(4), 933-937.

Smith, H.S. (2009). Current therapy in pain. Philadelphia, PA: Saunders Elsevier.

CredibleMeds powered by AZCERT.org. (2013). Composite List of All QT Drugs and the List of Drugs to Avoid for Patients with Congential LQTS. Retrieved from http://www.crediblemeds.org/everyone/compositelist-all-qtdrugs/. Accessed September 24, 2013. 25

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Walker, J.M., Farney, R.J., Rhondeau, S.M., Boyle, K.M., Valentine, K., Cloward, T.V., & Shilling, K.C. (2007). Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. Journal of Clinical Sleep Medicine, 3(5), 455-461.

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Oklahoma D.O. | January 2014

LEGISLATIVE REPORT provided by Matt Harney, MBA

Osteopathic Medicine Day at the Capitol The Oklahoma Osteopathic Association is hosting Osteopathic Medicine Day at the Capitol in Oklahoma City on Monday, March 3, 2014. Osteopathic Medicine Day allows osteopathic physicians, residents, and students the opportunity to communicate the importance of osteopathic medicine in Oklahoma directly with your state legislators. As our state faces a critical physician shortage, challenges to state funding for OSU Medical Center, and dangerous scope of practice overreaches, it is vital we inform our legislators of the valuable role osteopathic physicians play in the communities we serve. Lunch and a legislative briefing will be provided for all who participate. A brief program featuring legislative leadership will begin at 1 p.m. on the second floor of the capitol rotunda. Our osteopathic physicians, residents and students in attendance will be introduced from the House and Senate Floor. Also, meetings will be scheduled with your specific state legislators. To aid with these meetings, you will be provided with a packet containing talking points, a legislative directory and more. To participate in Osteopathic Medicine Day at the Capitol, please contact Matt Harney at matt@okosteo.org or 405-528-4848.

Bill Deadline passes, 2,235 bills filed

Oklahoma D.O. | PAGE 38

The bill deadline for the 2014 Oklahoma legislative session was Jan. 16, at 4 p.m. and concluded with a flurry of activity. In the House, 1,224 bills and resolutions were filed, and 1,011 were filed in the Senate, totaling 2,235 bills in the state legislature. A deluge of shell bills are contained within this sum. The biggest legislative agenda items for the osteopathic family include: transitioning funding for OSU Medical Center to a recurring annual appropriation, defending against multiple scope of practice overreaches, and protecting physician discretion regarding PMP consultation. Carryover bills from the previous session will also be monitored. HB 1020, a bill providing direct access for physical therapists, is currently dormant and could be heard. The legislative session began Feb. 3 and will end no later than May 30. The OOA lobbyists and staff are reviewing these bills to address those of interest or concern to the profession.

eLECTRONIC CIGARETTE USE AMONG TEENS RISE, LEGISLATION PROPOSED According to the Center for Disease Control, electronic cigarette

(e-cigarette) use among middle and high school students doubled from 2011 to 2012. The CDC estimates that a total of 1.8 million American youths have used an e-cigarette. Oklahoma law does not currently regulate e-cigarettes or vapor products therefore, stores can legally sell the products to minors. Most, but not all, e-cigarette products contain nicotine. Interim studies were requested in both the House and the Senate. The House study was cancelled, and the Senate scheduled the study for late January. On Dec. 10, Oklahoma State Sen. Frank Simpson announced he will be filing legislation this coming session to prevent youth access to e-cigarettes. The bill will be co-authored by Rep. Pat Ownbey in the House and will expand the definition of tobacco products in the Prevention of Youth Access to Tobacco Act to include all nicotine delivery products other than FDA-approved cessation aids. In a statement, Simpson, R-Ardmore, said: “As we know teenagers are at a very delicate point in their lives when it comes to physical and emotional development. Many of the habits developed by our young people as teenagers may well stay with them for the rest of their lives. Research has also shown that nicotine can have a negative impact on the physical development of youth. This is why we must do all we can to prevent them from using tobacco products.” Data from a 2013 study by the Oklahoma Youth Tobacco Survey (OYTS) shows 7.8 percent of Oklahoma high school students and

“

The use of e-cigarettes among youth is a great concern. Nicotine is a highly addictive substance that may negatively affect the developing brain. It’s important that we protect our youth.

”

-Rep. Pat Ownbey, R-Ardmore

2.7 percent of Oklahoma middle school students have used an e-cigarette in the past 30 days. This was the first year OYTS has included a question about e-cigarette use. There are currently no restrictions on the advertising of vapor products, unlike advertising restrictions on other tobacco products aimed at reducing youth exposure. Vapor products also are available in a variety of flavors, whereas flavored cigarettes were banned by the U.S. Food and Drug Administration in 2009 due to their

potential appeal to youth. The lack of restrictions related to sales to minors, advertising, and availability of flavors has resulted in a flood of new stores and will likely impact current and future use of e-cigarettes and vapor products by youth in Oklahoma. Oklahoma State Health Commissioner Terry Cline requested the legislation.

gABRIEL m. PITMAN, do, sPEAKS OUT AGAINST NURSE PRACTITIONER OVERREACH Gabriel M. Pitman, DO, Oklahoma Osteopathic Association trustee and co-chair of Patients First Coalition, was quoted in the Dec. 1 edition of The Oklahoman warning against possible overreaches by nurse practitioners. The article mentioned the attempt by New Mexico Gov. Susana Martinez to recruit nurse practitioners. New Mexico, unlike Oklahoma, does not require nurse practitioners to sign off on care for prescriptive authority. Martinez highlighted Oklahoma in a recent campaign announcement to further remove barriers for nurse practitioners considering moving to New Mexico and opening a practice. The decision to expand Medicaid in New Mexico has increased the demand for qualified health care professionals in the state. Meanwhile, Oklahoma has rejected Medicaid expansion. In Oklahoma, nurse practitioners cannot practice without physician supervision for prescriptive authority. Oklahoma law, however, does not require physician supervisors to review patient charts or even practice in the same building. The article in The Oklahoman highlighted two nurse practitioners claiming the benefits of practicing without physician supervision. However, several states require nurse practitioners to have a team leader or management from a more qualified health care professional. Unfortunately, some of these states have bills in 2014 that would reduce these patient protections. Fortunately, no similar bills have been filed in Oklahoma.

Oklahoma law requires a physician supervising a physician assistant to be on site at the clinic for a certain period of time each week but does not have the same requirement for nurse practitioners. The article can be found at: http://newsok.com/article/3909794

Oklahoma D.O. | January 2014

We feel that a physician must always serve as the team leader, as they are the only comprehensively trained health care professional prepared to make a diagnosis and establish a treatment plan. We feel direct access to non-physician health care professionals endangers patients’ health. We feel direct access also puts the patient in the unfortunate and confusing position of being forced to choose among the series of health care professionals, not all of whom are adequately trained to make well-informed diagnoses.

”

-Gabriel M. Pitman, DO, OOA Trustee

gOV. fALLIN IMPLIES OKLAHOMA HEALTH CARE AUTHORITY FUNDING WILL BE A PRIORITY Making up for reductions in the state’s federal contribution to the Medicaid program is a top budget priority, Gov. Mary Fallin said. Additional funding will be necessary due to changes in the Federal Medical Assistance Percentage (FMAP), the federal formula based on a state’s per capita income that is used to determine federal funding for state Medicaid programs. “We are warning state agencies not to expect a big budget increase because of federal law (changes), changes in (the Oklahoma Health Care Authority’s federal funding) formula…and the state’s requirement to fund the Department of Human Services’ Pinnacle Plan,” Fallin said at a recent meeting of the State Equalization Board that she chairs. Officials with the Oklahoma Health Care Authority learned after the agency prepared its initial budget request that its federal funding would be reduced by about 2.7 percent, or around $66 million. Other impacted agencies include the Department of Mental Health and Substance Abuse Services, the Department of Rehabilitative Services and the Department of Human Services. The Health Care Authority will lose the largest share of that amount, approximately $50 million. Lawmakers appropriated an additional $39.7 million to the Health Care Authority for fiscal year 2014. As part of a legal settlement, Oklahoma agreed to fully fund the Pinnacle Plan at the Department of Human Services. The Pinnacle Plan is a five-year plan to improve the agency’s child welfare services. Lawmakers appropriated an additional $44 million to DHS for the current fiscal year, primarily dedicated to the Pinnacle Plan. Annual compensation increases for child welfare workers, however, was not granted. Regarding the loss of FMAP funding, Fallin said, “we don’t have an option about funding those.” The governor said she, her staff and budget analysts from the Office of Management and Enterprise

Oklahoma D.O. | PAGE 39

Dr. Pitman said a physician is necessary to supervise health care professionals such as nurse practitioners and physician assistants because they aren’t as rigorously trained as doctors of osteopathic medicine or medical doctors. Dr. Pitman went on to say that the Oklahoma Osteopathic Association supports nurse practitioners and physician assistants in the roles they serve in the health care system—just not without supervision.

“

Services will be reviewing other agency requests for funding in the coming weeks.

“

There are other needs and a lot of requests for additional revenue. We will look at each one of those and consider them, but it really depends on the revenue.

”

-Oklahoma Gov. Mary Fallin

The Board of Equalization met Dec. 19 to consider its initial General Revenue Fund estimate for fiscal year 2015. Fallin used that estimate for constructing her initial budget proposal that was presented to lawmakers Feb. 3, the first day of the 2014 legislative session and the day she delivered her State of the State address. The General Revenue Fund is the largest source for legislative spending and includes revenue from taxes on alcoholic beverages, franchises, cigarettes and tobacco products, among others, that are not included in the analysis. Additional funds for appropriation come from other sources such as the State Judicial Revolving Fund and the Oklahoma Education Lottery Trust Fund among others. Lawmakers could have more money to spend during the 2014 legislative session if Oklahoma’s General Revenue Fund collections follow the trend of the past 10 years, the Office of Management and Enterprise Services reported. According to the Office of Management and Enterprise Services’ recently released State Budget Outlook Multi-Trend Analysis, fiscal year 2015 General Revenue Fund collections from its five major sources (individual income tax, corporate income tax, the gross production tax on natural gas, sales tax and motor vehicle tax) are projected to increase 6.8 percent, from the June estimate of $5.4 billion to $5.8 billion.

Health insurance marketplace sees december enrollment increase

Oklahoma D.O. | PAGE 40

The Obama administration successfully met a self-imposed Nov. 30 deadline to significantly improve the performance of its online health insurance exchange at www.heathcare.gov. The website had been marred by technical problems since its Oct. 1 rollout. The administration also dealt with facilitating the online marketplace for those states that refused to create and manage their own. In November, President Obama initiated a round-the-clock technical team to improve the website capacity and functionality. Despite these troubles, the White House is encouraged by the recent boosted traffic. On Dec. 3, administration officials said healthcare.gov received 1 million visitors on that day alone. Separately, Medicaid enrollment has also increased as a result of advertising for the Health Insurance Marketplace. These individuals qualified for traditional Medicaid but were not enrolled. The

report issued by the administration noted traditional Medicaid enrollment in states that expanded Medicaid increased by 16 percent, but states that did not expand Medicaid saw only a 4 percent increase in traditional Medicaid enrollment. Medicaid is available in all 50 states and Washington D.C. as are health insurance premium subsidies for individuals between 138 percent and 400 percent of the Federal Poverty Level (FPL). These health insurance premiums are available for individuals with an income of $15,856-$45,960 for an individual and $32,499-$94,200 for a family of four. Medicaid expansion, bridging the gap between traditional Medicaid and the lower range of premium subsidies (138 percent FPL), was intended as a requirement for all states as part of the Affordable Care Act. However, the Supreme Court struck down that requirement in favor of states having the right to opt out. Currently, 25 states and Washington D.C. have expanded Medicaid. In order to receive coverage through the marketplace by Jan. 1, applications must have been submitted and a plan purchased by Dec. 23, 2013. Open enrollment for the following year continues through March 31, 2014.

Fiscal impact of Oklahoma’s failure to expand medicaid In 2012, the United States Supreme Court ruled to allow states the choice to expand Medicaid rather than being required to as a component of the Affordable Care Act passed in 2010. Traditional Medicaid coverage varies somewhat from state to state. Health insurance premium subsidies begin at 138 percent of the FPL or $15,856 for an individual. For now, individuals in Oklahoma who earn below this amount but do not qualify for traditional Medicaid will continue to struggle without insurance. At this point, Medicaid expansion appears to be little more than a political game. The fiscal reality points to great gains for those states that decide to expand, as the federal government pays for the entire cost for the first three years and will pay no less than 90 percent thereafter. By 2022, the budgetary impact of Medicaid expansion averages less than 1 percent of entire state budgets, according to the Kaiser Commission on Medicaid and the Uninsured. A December 2013 issue brief by The Commonwealth Fund analyzed projected federal spending for Medicaid expansion. The brief calculated funding for the year 2022 using Medicaid enrollment and spending estimates by the Urban Institute. For comparison to other federal subsidies provided to states, the issue brief also calculated spending projections for federal highways, defense procurement contracts, as well the as costs to attract private businesses to the state through subsidies, deductions and tax cuts. Similar to revenue collection for all federal defense contracts and most of federal highway funding, Medicaid funds are transferred to states through federal general revenue collection. Said revenues are raised from residents in every state regardless of the willingness of individual states to accept these revenue collections from the federal government. Research indicates that no state that rejects Medicaid expansion would receive a positive flow of funds. As the federal portion of Oklahoma D.O. | January 2014

expansion funding is significantly greater than the state portion, those in non-expansion states are negatively affected by still paying for the cost of expansion and yet are not accepting the benefits. The analysis showed the following figures Oklahoma is set to receive in 2022 for the following (at least partially) subsidized federal programs provided to the states: Federal Highway Transportation Funds: $815 million Federal Defense Procurement Contracts: $3.08 billion Medicaid expansion: $1.25 billion* *The $1.25 billion represents the revenue Oklahoma stands to lose through continued rejection of Medicaid expansion. This lost revenue amounts to nearly 18 percent of Oklahoma’s annual budget. Additionally, Oklahoma forgoes $2.71 billion in revenue through state incentives to attract private businesses through tax cuts, deductions and subsidies despite having a state budget of approximately $7 billion. According estimates from the Oklahoma Health Care Authority, 180,000 Oklahomans would be eligible to gain health insurance coverage by expanding Medicaid to 138 percent of FPL. These individuals earn less than $15,856 annually. The Oklahoma Health Care Authority has created a stat sheet related to health care in Oklahoma and can be found here: https://dl.dropboxusercontent. com/u/85965051/OHCAStatisticsMedicaidExpansion7-23-12. pdf

The law replaces the state’s judicial workers’ compensation system with an administrative system. The new law allows employers to opt out of the state system as long as equivalent benefits are provided to injured employees. However, three justices indicated the opt-out provision could be constitutionally challenged if the administrative system does not provide equal benefits upon implementation. The new system goes into effect in February of 2014.

Affordable CARE ACT Changes to health care beginning jan. 1, 2014 Provided by the U.S. Department of Health & Human Services Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition” — that is, a health problem that developed before the child applied to join the plan.

The 2014 legislation session shall provide an opportunity for the state’s leaders to reconsider the possibility of Medicaid expansion. Republican governors in Arizona and Ohio have expanded Medicaid.

What This Means for You Until now, plans could refuse to accept anyone because of a preexisting health condition, or they could limit benefits for that condition.

The Commonwealth Fund was started in 1918 by Anna Harkness. Harkness was the widow of the late Stephen V. Harkness, an initial investor in Standard Oil Company. Ms. Harkness was among the first women to establish a foundation and mandated that the Commonwealth Fund should “do something for the welfare of mankind.”

Now, under the health care law, plans that cover children can no longer exclude, limit, or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage.

The issue brief by The Commonwealth can be found here: http:// www.commonwealthfund.org/~/media/Files/Publications/ Issue%20Brief/2013/Dec/1718_Glied_how_states_stand_gain_ lose_Medicaid_expansion_ib_v2.pdf

On Dec. 16, the Oklahoma Supreme Court upheld the constitutionality of the new workers’ compensation law. The Supreme Court determined the law does not violate the single-subject rule, allowing only one subject in a single bill. The majority opinion wrote, “As all sections of the law are interrelated and refer to a single subject, workers’ compensation or the manner in which employees may ensure protection against work-related injuries, we disagree with the constitutional challenge to the Administrative Act on grounds of logrolling.”

Oklahoma D.O. | January 2014

Some Important Details • This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage. • The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010. • Starting in 2014, these protections will be extended to Americans of all ages. Coverage for adults may be available under the Pre-Existing Condition Insurance Plan. Eliminating Annual Limits on Insurance Coverage. The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive.

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new workers’ compensation law upheld by oklahoma supreme court

This rule applies to all job-related health plans as well as individual health insurance policies issued after March 23, 2010. The rule will affect your plan as soon as it begins a plan year or policy year on or after Sept. 23, 2010.

Lifetime & Annual Limits The Affordable Care Act prohibits health plans from putting a lifetime dollar limit on most benefits you receive. The law also restricts and phases out the annual dollar limits a health plan can place on most of your benefits — and does away with these limits entirely in 2014.

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What This Means for You Before the health care law, many health plans set an annual limit — a dollar limit on their yearly spending for your covered benefits. Many plans also set a lifetime limit — a dollar limit on what they would spend for your covered benefits during the entire time you were enrolled in that plan. You were required to pay the cost of all care exceeding those limits. • Under the law, lifetime limits on most benefits are prohibited in any health plan or insurance policy issued or renewed on or after Sept. 23, 2010. • The law restricts and phases out the annual dollar limits that all job-related plans, and individual health insurance plans issued after March 23, 2010, can put on most covered health benefits. Specifically, the law says that none of these plans can set an annual dollar limit lower than: o $750,000: for a plan year or policy year starting on or after Sept. 23, 2010, but before Sept. 23, 2011. o $1.25 million: for a plan year or policy year starting on or after Sept. 23, 2011, but before Sept. 23, 2012. o $2 million: for a plan year or policy year starting on or after Sept. 23, 2012, but before Jan. 1, 2014. • No annual dollar limits are allowed on most covered benefits beginning Jan. 1, 2014. Some Important Details • Be aware that plans can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not considered “essential.” • If the new rules apply to your plan, they will affect you as soon as you begin a new plan year or policy year on or after Sept. 23, 2010. (For example, if your policy has a calendar plan year, the new rules would apply to your coverage beginning Jan. 1, 2011). • If you have a “grandfathered” individual health insurance policy, your health plan is not required to follow the new rules on annual limits. (A grandfathered individual health insurance policy is a plan that you bought for yourself or your family; that you did not receive through your employer; and that was issued on or before March 23, 2010.) If you’re not sure whether your plan is grandfathered, ask your insurance company. • The ban on lifetime dollar limits for most covered benefits applies to every health plan — whether you buy coverage for yourself or your family, or you receive coverage through your employer. • Some plans may be eligible for a waiver from the rules concerning annual dollar limits, if complying with the limit would mean a significant decrease in your benefits coverage or a significant increase in your premiums.

Making Care More Affordable. Tax credits to make it easier for the middle class to afford insurance will become available for people with income between 100 percent and 400 percent of the poverty line who are not eligible for other affordable coverage. (In 2010, 400 percent of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower your premium payments each month, rather than making you wait for tax time. It’s also refundable, so even moderate-income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles). Establishing the Health Insurance Marketplace. Starting in 2014 if your employer doesn’t offer insurance, you will be able to buy it directly in the Health Insurance Marketplace. Individuals and small businesses can buy affordable and qualified health benefit plans in this new transparent and competitive insurance marketplace. The Marketplace will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, members of Congress will be getting their health care insurance through the Marketplace, and you will be able buy your insurance through Marketplace, too. Increasing the Small Business Tax Credit. The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50 percent of the employer’s contribution to provide health insurance for employees. There is also up to a 35 percent credit for small non-profit organizations. The Affordable Care Act helps small businesses and small tax-exempt organizations afford the cost of covering their employees. What This Means for You If you have fewer than 25 employees and provide health insurance, you may qualify for a tax credit of up to 35 percent (up to 25 percent for non-profits) to offset the cost of your insurance. This credit will increase in 2014 to 50 percent (35 percent for non-profits). This will make the cost of providing insurance much lower. Promoting Individual Responsibility. Under the law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption. *Increasing Access to Medicaid. Americans who earn less than 133 percent of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing to 90 percent federal funding in subsequent years. *Oklahoma has rejected Medicaid expansion

Ensuring Coverage for Individuals Participating in Clinical Trials. Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial. Applies to all clinical trials that treat cancer or other life-threatening diseases. Oklahoma D.O. | January 2014

Support OOPAC in 2014! DO your part To protect and promote osteopathic medicine in Oklahoma. 2014 OOPAC Investment _____ My personal check made payable to â&#x20AC;&#x153;OOPACâ&#x20AC;? is enclosed [ ] $100

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[ ] $2,500+ (Platinum PAC Partner) _____ Yes! I commit to monthly contributions to OOPAC. Please charge my credit card: [ ] $2,508 ($209 per month)

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Account number: ____________________________________________ Expiration date: _______ Name as it appears on card: _______________________________________ CID: ______________ Address: __________________________________________________________________________________ City, State, Zip: ___________________________________________________________________________ Occupation: __________________________________ Employer: _______________________________

I declare that this contribution is freely and voluntarily given from my personal property. I have not directly or indirectly been compensated or reimbursed for the contribution. This personal contribution is not deductible as a donation or business expense.

Oklahoma D.O.

Please mail to: OOPAC, 4848 N. Lincoln Blvd., Oklahoma City, OK 73105-3335.

PAGE 43

Signature: ________________________________________________________________________________

Oklahoma D.O. | January 2014

What DO’s Need To

KNOW

CMS Strategy to Combat Medicare Part D Prescription Drug Fraud and Abuse Prescription drug abuse is a serious and growing problem nationwide. Unfortunately, the Medicare Part D prescription drug program (Part D) is not immune from the abuses associated with this nationwide epidemic. The Centers for Medicare & Medicaid Services (CMS) takes this problem seriously and is taking steps to protect Medicare beneficiaries and the Medicare Trust fund from the harm and damaging effects associated with prescription drug abuse. CMS’ fraud and abuse strategy for Part D is data driven and focuses on the validation and analysis of Part D claims data (Prescription Drug Event, or PDE, data) that CMS receives from Part D sponsors. We are leveraging CMS’ access to all PDE data and using it to guide our anti-fraud efforts and share the results of our analysis with Part D plan sponsors, law enforcement agencies and pharmacy and physician licensing boards, as appropriate, so this information can assist our joint efforts to combat fraud and abuse. A centerpiece of this strategy that focuses on protecting beneficiaries is the identification of Part D enrollees who have potential opioid or acetaminophen overutilization issues that indicate the need to implement appropriate controls on these drugs for the identified beneficiaries. In addition, data analysis is employed to identify prescribers and pharmacies that may warrant further action to curb fraudulent or abusive activities. With the proposed rule issued Jan. 6, 2014, CMS seeks to provide the agency with new tools to employ when problematic prescribers and pharmacies are identified. The key provisions of the proposed rule are discussed below, as are the ongoing CMS actions to combat fraud and abuse. Fraud and Abuse Provisions in the CY 2015 Policy & Technical Changes to the Medicare Advantage and Prescription Drug Program Proposed Rule Require that Prescribers of Part D Drugs Enroll in Medicare: Section 6405 of the Affordable Care Act requires that physicians and nonphysician practitioners who order durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) or certify home health care must be enrolled in Medicare. The statute also permits the Secretary to extend these Medicare enrollment requirements to physicians and non-physician practitioners who order or certify all other categories of items or services in Medicare, including covered Part D drugs. CMS is proposing to require that physicians and non-physician practitioners who write prescriptions for covered Part D drugs must be enrolled in Medicare for their prescriptions to be covered under Part D. Impact of Proposal: Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals.

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Permit Revocation of Medicare Enrollment for Abusive Prescribing Practices and Patterns: CMS is proposing to add authority to revoke a physician’s or eligible professional’s Medicare enrollment if: • CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive and represents a threat to the health and safety of Medicare beneficiaries or otherwise fails to meet Medicare requirements; or • His or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked; or • The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs. Impact of Proposal: Providing CMS the authority to revoke such prescribers’ Medicare enrollment and would help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse. Provide Direct Access to Part D Sponsors’ Downstream Entities: The proposed provision would provide CMS, its antifraud contractors, and other oversight agencies the ability to request and collect information directly from pharmacy benefit managers, pharmacies and other entities that contract or subcontract with Part D Sponsors to administer the Medicare prescription drug benefit. Impact of Proposal: The provision would streamline CMS’ and its anti-fraud contractors’ investigative processes. Currently, it can take a Oklahoma D.O. | January 2014

long time for CMS’ contractors who are often assisting law enforcement to obtain important documents like invoices and prescriptions directly from pharmacies, because they must work through the Part D plan sponsor to obtain this information. This proposal is designed to provide more timely access to records, including for investigations of Part D fraud and abuse, and responds to recommendations from the Department of Health and Human Services (HHS) Office of Inspector General. Improve Payment Accuracy: The proposed regulation also would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments. Impact of Proposal: The provision would codify and clarify rules regarding when Part D and MA plan sponsors must report and return overpayments. Results of Ongoing CMS Actions Against Part D Fraud and Abuse Reduction in the number of Medicare beneficiaries receiving coverage for prescription drugs that threaten their health and safety. The Medicare Part D Overutilization Monitoring System (OMS) was fully implemented on July 31, 2013, to help CMS ensure that sponsors have established reasonable and appropriate drug utilization management programs to assist in preventing overutilization of prescribed medications. CMS provides quarterly reports to sponsors on beneficiaries with potential opioid or acetaminophen overutilization issues identified through analyses of PDE data and through beneficiaries referred by the CMS Center for Program Integrity (CPI). Sponsors are required to respond to CMS within 30 days on the status of the review for each beneficiary case. The principle performance metric for OMS is the number and percentage of acetaminophen and opioid overutilizers. An initial comparison with 2011 PDE data pre-dating the implementation of OMS shows there has already been a substantial reduction in the number of acetaminophen and opioid overutilizers in Medicare Part D. How the Proposed New Timeline for the EHR Incentive Programs Affects You Last month, CMS and the Office of the National Coordinator for Health Information Technology (ONC) announced the intent to change the Stage 3 timeline and extend Stage 2 of meaningful use through 2016. Important to note about the proposed timeline • It does not delay the start of Stage 2 of meaningful use. • It does not affect the current reporting periods and deadlines for 2014 participation. What this Means for You If you begin participation with your first year of Stage 1 for the Medicare EHR Incentive Program in 2014: • You must begin your 90 days of Stage 1 of meaningful use no later than July 1, 2014 and submit attestation by Oct. 1, 2014 in order to avoid the 2015 payment adjustment. If you have completed 1 year of Stage 1 of meaningful use: • You will demonstrate a second year of Stage 1 of meaningful use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid. • You will demonstrate Stage 2 of meaningful use for two years (2015 and 2016). • You will begin Stage 3 of meaningful use in 2017.

Please be sure to look for additional guidance in the Federal Register for rulemaking on this proposal.

Oklahoma D.O. | January 2014

PAGE 45

• You will still demonstrate Stage 2 of meaningful use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid. • You will demonstrate Stage 2 of meaningful use for three years (2014, 2015 and 2016). • You will begin Stage 3 of meaningful use in 2017.

Oklahoma D.O.

If you have completed two or more years of Stage 1 of meaningful use:

CENTER FOR HEALTH SCIENCES David F. Hitzeman, DO, FACOI, Editor Professor of Medicine Department of Internal Medicine Treatment of Newly Diagnosed Diabetes Patients After Bypass Surgery Jennifer St John, DO Internal Medicine Resident Oklahoma State University Medical Center Jeffrey S. Stroup, PharmD, BCPS Associate Professor of Medicine Oklahoma State University Center for Health Sciences

Oklahoma D.O. PAGE 46

INTRODUCTION Type 2 diabetes mellitus is a chronic, progressive, multifactorial disease that affects an estimated 25.8 million adults (8.3% of the population) in the United States (1). In addition, 79 million Americans aged 20 years or older have prediabetes (1). Diabetes is associated with significant morbidity, ranking as the leading cause of renal failure, new-onset blindness, and limb amputations (1,2). Diabetes is an independent risk factor for cardiovascular disease (CVD) in both men and women (3). In addition CVD is the leading cause of death in patients with diabetes (3). The costs of care associated with diabetes are staggering. Data from 2012 suggest that in the United States diabetes costs were approximately 245 billion dollars [176 billion direct and 69 billion in lost productivity] (4). In 2010, approximately 10.1% of the Oklahoma population was diagnosed with diabetes (2). Several patient’s that present to medical centers have little contact with medical care outside of the emergency department setting, carry no diagnosis of chronic disease, and therefore consider themselves “healthy”. Frequently these patients are admitted for one complaint and upon discharge they often find themselves facing multiple diagnoses and several lifestyle changes. In the Unit-

Oklahoma State University Center for Health Sciences College of Osteopathic Medicine 1111 West 17th Street Tulsa, Oklahoma 74107-1998

ed Kingdom Prospective Diabetes Study (UKPDS), up to fifty percent of people diagnosed with type 2 diabetes presented with developing complications at diagnosis particularly retinopathy (5). Therefore, several patients had complications of disease (macrovascular and microvascular) prior to diagnosis. Our study aimed to look at admissions that ultimately result in coronary artery bypass grafting (CABG), specifically those that also carry a new diagnosis of diabetes mellitus at the time of discharge. In this population of patients, tight glycemic control has been shown to decrease morbidity and mortality post-operatively and for that reason all patients are started on an insulin drip upon return from CABG surgery to maintain normal glycemic control (6). As a result we suspected many of these patients would go home on insulin therapy when oral therapies may be a more appropriate option. The use of insulin therapy in a newly diagnosed population may put those patients at high risk for hypoglycemia and other complications (7,8). The American Association of Clinical Endocrinologists (AACE) guidelines, most recently published in 2013, indicated that insulin is not first line therapy for newly diagnosed patients with diabetes unless their hemoglobin A1c is greater than 9% (9). In addition, the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) guidelines suggest insulin therapy as a transitional increase from monotherapy or dual therapy in patient’s not achieving their goals of therapy (10). Our hypothesis in this study was that a large percentage of patients who undergo CABG are sent home on insulin therapy even

though oral therapy may have been most appropriate. This use of insulin may place patients at high risk of hypoglycemia. POPULATION Medical records for those patients undergoing CABG from April 2011 to April 2012 were requested for review. Inclusion criteria included any of the following: new diagnosis of diabetes mellitus during admission, hemoglobin A1c of 6.5% or greater without previous mention of diabetes or use of anti-diabetes therapies prior to admit, and discharge on anti-diabetes regimens without any mention of diabetes diagnosis and no diabetes medications upon admission. Exclusion criteria were the following: diagnosis of diabetes present on admission, use of anti-diabetes medications prior to admission, death prior to discharge, and age <18 years. METHODS We reviewed all charts for all admissions resulting in CABG that occurred from April 2011 to April 2012. Admission diagnosis, past medical history, admission medication list, discharge diagnoses, and discharge medication lists were reviewed for inclusion and exclusion criteria. A simple data sheet was used to compile information for each record and those meeting requirements were included in the final analysis. Collected information included hemoglobin A1c, discharge anti-diabetes medications, and arrangement for follow up or any instructions for bridging of insulin to oral medications. RESULTS For the examined time period 111 patients underwent CABG. Five patients died prior to discharge, forty-six patients had a diagnosis of diabetes and were on anti-diabetes medications prior to admission, and forty-

Oklahoma D.O. | January 2014

four patients did not receive diabetes therapy at discharge. A total of eighteen charts (16%) met criteria for analysis (See Table). DISCUSSION Surgical clinical trial data supports that strict glycemic control is important in the post-operative period to promote wound healing and prevent complications (6). This is especially important after thoracic surgeries like CABG in patients with and without diabetes (6,11). Insulin is the primary agent for achieving this goal in diabetics and non-diabetic patients with hyperglycemic excursions in the hospital (12). Use of insulin therapy at discharge in this population necessitates frequent home glucose checks, injection administration education, and has the highest risk of hypoglycemia among all anti-diabetic medications (13). The prescriber must also take into consideration the patientâ&#x20AC;&#x2122;s ability and willingness to use insulin. The AACE treatment guidelines specifically utilize outpatient insulin therapy when the hemoglobin A1c level reaches 9% and the patient has

symptoms relating to hyperglycemia. Following these principles, only one patient in our study would possibly need insulin, yet four were discharged on this medication. Interestingly enough, the one patient that should have been considered for outpatient insulin was discharged on metformin monotherpay. Good options exist for oral medications to control mild hyperglycemia and postprandial elevations. Metformin is a first line agent that is inexpensive and has many years of data showing safety and efficacy (14). For people with renal impairment and those who develop gastrointestinal or other side effects there are multiple oral agents that are equally efficacious including dipeptidyl peptidase (DPP) IV inhibitors and sodium glucoselike transporter (SGLT)-2 inhibitors (15,16). All of these agents are useful because they lack the risk of hypoglycemia as compared to insulin and sulfonylurea therapy. In these patients studied, many will only require transient assistance with

glucose control upon discharge due to the dissipating stresses as time from the operative period grows. This is usually controlled with an oral agent, especially for those who do not carry a preexisting diagnosis of diabetes, with far less risk of hypoglycemia. CONCLUSION In patients who undergo CABG surgery optimal glycemic control during the pre, intra, and post-operative time periods is the standard of care. In those patients who have no history of diabetes and hemoglobin A1c levels <9% oral agents such as metformin, DPP-IV inhibitors, or SGLT-2 inhibitors may be considered. Insulin therapy is an option, but may place patients at higher risk of hypoglycemia as compared to these agents.

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Oklahoma D.O. | January 2014

REFERENCES

1. 2013 Fast Facts. Data and statistics about diabetes. Available online at: http://professional.diabetes.- org/ResourcesForProfessionals. aspx?cid=91777&loc=dorg-statistics.

2. Centers for Disease Control and Prevention. Diabetes Report Card 2012. Atlanta, GA: Centers for Dis ease Control and Prevention, US De partment of Health and Human Ser vices; 2012.

3. Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, Mitch W, Smith SC Jr, Sowers JR. Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation. 1999; 100:1134-46.

4. American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes Care. Diabetes Care. 2013; 36:1033-46. 5. UK Prospective Diabetes Study (UKPDS) Group. UK prospective diabetes study VIII. study design, progress and performance. Diabetolo gia. 1991; 34: 877â&#x20AC;&#x201C;890.

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6. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR, Haan CK, Svedje- holm R, Taegtmeyer H, Shemin RJ; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. The Society of Thoracic Surgeons Practice Guideline Series: Blood Glucose Man- agement During Adult Cardiac Sur gery. Ann Thorac Surg. 2009; 87: 663- 669.

7. Frier BM, Schernthaner G, Heller SR. Hypoglycemia and cardiovascular risk. Diabetes Care. 2011; 34 (suppl 2): S132-S137.

8. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabtes. Diabetes Care. 2003; 26: 1902-1912.

9. Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgar- den ZT, Bush MA, Dagogo-Jack S, Davidson MB, Einhorn D, Garvey WT, Grunberger G, Handelsman Y, Hirsch IB, Jellinger PS, McGill JB, Mechanick JI, Rosenblit PD, Umpier- rez G, Davidson MH; American As- sociation of Clinical Endocrinologists. AACE comprehensive diabetes man-

agement algorithm 2013. Endocr Pract. 2013;19: 327-36.

10. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR; American Diabetes Association (ADA); Eu- ropean Association for the Study of Diabetes (EASD). Management of hy perglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35: 1364-79.

11. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continu- ous intravenous insulin infusions on outcomes of cardiac surgical pro- cedures: the Portland Diabetic Proj- ect. Endocr Pract. 2004;10 (Suppl 2): 21-33.

12. Lien LF, Angelyn Bethel M, Feinglos MN. In-hospital management of type 2 diabetes mellitus. Med Clin North Am. 2004; 88:1085-105.

13. Solomon MD, Vijan S, Forma FM, Conrad RM, Summers NT, Lakdawalla DN. The impact of insulin type on severe hypoglycaemia events requiring inpatient and emergency department care in patients with type 2 diabetes. Diabetes Res Clin Pract. 2013 Oct 1. [Epub ahead of print]

14. Hirst JA, Farmer AJ, Ali R, Roberts NW, Stevens RJ. Quantify- ing the effect of metformin treatment and dose on glycemic control. Diabe- tes Care. 2012; 35: 446-54.

16. Vasilakou D, Karagiannis T, Athanasiadou E, Mainou M, Liakos A, Bekiari E, Sarigianni M, Matthews DR, Tsapas A. Sodiumâ&#x20AC;&#x201C;Glucose Cotransporter 2 Inhibitors for Type 2 Diabetes: A Systematic Review and Meta-analysis. Ann Intern Med. 2013;159: 262-274.

15. Dicker D. DPP-4 inhibitors: impact on glycemic control and cardiovascular risk factors. Diabetes Care. 2011; 34 (Suppl 2): S276-8.

Oklahoma D.O. | January 2014

Bureau News: From the American Osteopathic Association Communications Department

Bureau on Membership The OOA Board of Trustees welcomes the following new members to the OOA family! HEALTH FOR THE WHOLE FAMILY “Your Pneumonia Protection Plan”

Lee A. Kirsch, DO Family Practice (Oklahoma City) LaToya T. Smith, DO OB/GYN (Midwest City)

DOs and other members of the profession consider the American Osteopathic Association’s “Health for the Whole Family” series a great way to promote the profession and educate patients about a variety of health topics. To use this month’s article, you have permisson to simply make copies of the article (see page 50) for use in your office waiting room to help educate your patients about current health care issues.

“As physicians, we have so many unknowns coming our way... One thing I am certain about is my malpractice protection.” Medicine is feeling the effects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to uncertainty and lack of control. What we do control as physicians: our choice of a liability partner. I selected ProAssurance because they stand behind my good medicine. In spite of the maelstrom, I am protected, respected, and heard. I believe in fair treatment—and I get it. Oklahoma D.O. PAGE 49

Professional Liability Insurance & Risk Management Services ProAssurance Group is rated A+ (Superior) by A.M. Best. ProAssurance.com • 800.282.6242

Oklahoma D.O. | January 2014

Your Pneumonia Protection Plan Is that cough and shortness of breath signs of a mild cold or the flu? Or, are they signs of something much more serious, like pneumonia? It’s hard to tell if you don’t have the facts. While most people have heard of pneumonia, not many are aware of the symptoms associated with this potentially dangerous lung infection. Pamela A. Georgeson, DO, an osteopathic allergist and immunologist from Chesterfield Township, Mich., details the signs and symptoms of pneumonia so you can stay a step ahead of the illness this winter season. Danger Signs of Pneumonia “Pneumonia is a lung infection marked by inflammation of the air sacs in one or both lungs,” says Dr. Georgeson. It often develops after a viral infection, like the flu, so people regularly confuse its symptoms with those of the flu or common cold. So, what are the specific symptoms of pneumonia to watch for? “Once the lungs are infected or become inflamed, sufferers may experience cough with phlegm, fever, chills, chest pain, nausea and vomiting, or difficulty breathing,” Dr. Georgeson says. She advises sufferers to visit their local emergency room if these symptoms persist or if they develop more severe symptoms such as: • Blood in phlegm • Bluish-toned skin • Labored and heavy breathing • Mental confusion or reduced mental function (in the elderly) • Rapid heart rate • Weight loss “The severity of symptoms varies among children, adults and the elderly,” notes Dr. Georgeson. “While newborns may not show any signs, or they may vomit, have a fever, and have difficulty breathing or eating, older people may have sudden changes in mental awareness and experience lower body temperature and energy levels,” she continues. For both infants and adults alike, Dr. Georgeson says it is imperative they receive medical attention at the first sign of symptoms and see a primary health care provider for follow-up if symptoms linger or worsen. Diagnosis and Treatment When diagnosing pneumonia, your physician will ask about symptoms and complete a physical examination; they may also request a chest x-ray or blood test. “For most people, pneumonia will clear up in two to three weeks with the aid of antibiotics, cough medicine, and rest; however, for older adults, infants, and people with other chronic illnesses who have become extremely ill, hospital treatment is usually required,” explains Dr. Georgeson. Stopping the Spread of Pneumonia “Pneumonia is an extremely contagious illness, which spreads through respiratory droplets transmitted through sneezes, coughs, and exhales,” explains Dr. Georgeson. That is why it is especially important for at-risk people to safeguard themselves before they become infected. “If you are 65 or older, smoke, or have a heart or lung problem, you should get a pneumococcal vaccine and a flu shot,” recommends Dr. Georgeson. “While it may not prevent you from getting pneumonia, it will reduce the severity of symptoms if you get sick.”

Oklahoma D.O. PAGE 50

Winter Wellness Tips There are a few general tips that you can implement into your daily routine to avoid getting sick this season. According to Dr. Georgeson, the best ways to prevent and stop the spread of viruses and bacteria that cause pneumonia and other illnesses is to take good care of yourself and be mindful of spreading germs. “If you’re healthy, stay away from people who have the flu, colds, measles, or chickenpox, since your chances of developing pneumonia increase after getting one of these illnesses. If you’re sick, wash hands with soap and water often, always cover your mouth and nose when sneezing, drink lots of fluids, get plenty of rest, and most important, stay home if you’re sick,” she advises.

Preventive medicine is just one aspect of care osteopathic physicians (DOs) provide. DOs are fully licensed to prescribe medicine and practice in all specialty areas, including surgery. DOs are trained to consider the health of the whole person and use their hands to help diagnose and treat their patients.

Oklahoma D.O. | January 2014

The Journal of the Oklahoma Osteopathic Association

OKLAHOMA

May/June 2012 May/June 2013

D.O.

2013-2014 Directory Order Form I would liked to order______ copies of the 2014 directory @ $55 per directory. Shipping and Handling is not included in the price, please call for pricing (405) 528-4848 or (800) 522-8379 PAYMENT INFORMATION: 1 I have enclosed a check in amount of $__________. 1 Please bill my credit card

Check card type: ______VISA ______MC ______AMX ______ DSC_____

Card Number:_____________________________________________

Name on Credit Card: _______________ _______________________ Signature: ___________________________Exp. Date____________

BILLING INFORMATION:

Company: __________________________________________________________ Contact Person: _____________________________________________________

Address: ___________________________________________________________

City: _____________________________________ State: _______ Zip: _________

Phone: ________________________________ Email: _______________________

Please return form by mail or fax

Oklahoma D.O. | January 2014

FAX TO: (405) 528-6102

PAGE 51

Mail: 4848 N. Lincoln Blvd. Oklahoma City, OK 73105-3335

Oklahoma D.O.

January Birthdays

Oklahoma D.O. PAGE 52

January 1 Henry M. Allen, DO Theron J. Bliss, DO Donald E. Brooks, DO Jerry D. Cockerell, DO Cindy E. Durr, DO Michael H. Grandison, DO Tammy Jarvis, DO Cornelia O. Mertz, DO Haﬁda R. Mumallah, DO Donna J. Price, DO David B. Siegel, DO Michael H. Tollett, DO John R. Winningham, DO January 2 Jim L. Burke, DO David K. Eslicker, DO Kurt R. Feighner, DO January 3 James T. Cail III, DO Jeffrey S. Halsell, DO Christine E. Narrin-Talbot, DO M. Sean O’Brien, DO Paul D. Ott, DO Laura K. Taylor, DO January 4 Bradley T. Anderson, DO Thomas A. Ward, DO Theodore M. Ware, DO January 5 Brent D. Bell, DO Kenneth E. Graham, DO John A. Saurino, DO James S. Seebass, DO Warren S. Silberman, DO Candy Ting, DO Jonathan C. Williams, DO Kristin L. Wills, DO January 6 William J. Guthrie, DO John K. Honeywell, DO

January 7 Dennis S. Blackstad, DO W. Stephen Eddy, DO James D. Harris, DO Steven E. Hebblethwaite, DO O. Joe Looper, DO Kevin M. Penwell, DO Patti W. Shaw, DO January 8 Benjamin R. Crawford, DO Gordon P. Laird, DO Curtis E. McElroy, DO Jennifer A. McKissick, DO Robert G. Stone, DO Robert S. Thomas, DO Soledad Wang, DO January 9 Lisa E. Hart, DO January 10 Misty Q. Branam, DO Gary L. Hills, DO January 11 Jessica L. Brown, DO Tessa L. Chesher, DO Martha A. Malone, DO Minta Z. Tauer, DO January 12 Marc Jason Davis, DO A. Cole Nilson, DO Jon E. Orjala, DO Stephen W. Woodson, DO January 13 J. Michael Fitzgerald Sr., DO Corey E. Mayo, DO Rick G. McKinney, DO January 14 Joyce A. Brown, DO Matthew D. Cohen, DO Donald L. Harker, DO Leroy O. Jeske, DO Christopher V. Moses, DO Amish R. Patel, DO James P. Riemer, DO Oklahoma D.O. | January 2014

January 15 Fiorella Avant, DO Gary E. Grifﬁn, DO Daniel C. Martin, DO James M. Rascoe, DO Cristopher D. Schultz, DO Stan R. Sherman, DO Thomas A. Showalter III, DO January 16 Tracy S. Sanford, DO January 17 Brent W. Davis, DO Elisa Depani-Sparkes, DO Hans Fichtenberg, DO Gregory P. Kelley, DO January 18 Carl N. Grifﬁn, DO Michael J. Milligan, DO H. Dean Vaughan, DO January 19 James J. Trusell, DO Darrin L. Webster, DO January 20 Nicholas G. Bull, DO Jeffrey A. Duncan, DO G. Wayne Flatt, DO Kristopher K. Hart, DO Eddie R. Stewart, DO Scott E. Williams, DO

January 21 Gary L. Badzinski, DO George J. Bovasso Jr., DO Darci Decker Coffman, DO Ryan N. Hulver, DO Therron S. Nichols, DO

January 26 Tom E. Denton, DO Mark O. Duncan, DO Gary L. McClure, DO William J. Myers, DO Nathan S. Roberts, DO Gerard F. Shea, DO

January 22 Heather L. Bell, DO Travis M. Brown, DO Vincent M. Bryan, DO Christine D. Clary, DO Michael K. Cole, DO Ronald Jeff Goodell, DO January 23 Christopher A. Back, DO Tracy A. Kidwell, DO Lindsay Anne Marshall, DO Shawn E. Minor, DO Michael S. Morrow, DO Keith P. Sutton, DO Julie D. Thomas-Pinkston, DO January 24 Lonette A. Bebensee, DO L. Drew Eldridge, DO Michael D. Kelly, DO William E. Moore, DO T. Joe Morgan, DO Timothy J. Moser, DO Melanie R. Pearce, DO Randall C. Raine, DO Edward J. Sokolosky, DO

January 27 Brent D. Chandler, DO Heather D. Rector, DO Melvin L. Robison, DO Sidney E. Semrad, DO Matthew G. Silva, DO Michael K. Steele, DO January 28 Michael P. Carney, DO Jeanette Marie Kelley, DO January 29 Brian J. Drake, DO Jennifer Eischen Galbraith, DO R. Gregory Martens, DO

January 31 Patrice A. Aston, DO Daniel Brown, DO

Oklahoma D.O. | January 2014

PAGE 53

The OOA wishes a very happy birthday to all of our DOs who celebrate their birthday this month!

Oklahoma D.O.

January 25 Monte R. McAlester, DO Adelaide L. Priester-Milford, DO Rene Z. Smith, DO Paul A. Whitham, DO

January 30 Joshua J. Livingston, DO W. John Mallgren, DO Michael S. Nick, DO David Quy, DO Shelly R. Zimmerman, DO

ER, D

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Oklahoma D.O. PAGE 54

D family f

OKLAHOMA OSTEOPATHIC ASSOCIATION presents a ONE HUNDRED FOURTEENTH ANNUAL CONVENTION April 24-27, 2014 at the NORMAN EMBASSY SUITES-HOTEL AND CONFERENCE CENTER convention chair MICHAEL K. COOPER, DO, FACOFP professional program chair C. MICHAEL OGLE, DO the following PROFESSIONAL PROGRAM approval requested for 30 1A AOA CREDITS and program requested for 30 AAFP CREDITS from the AMERICAN ACADEMY OF FAMILY PHYSICIANS

GENERAL AUDIENCE ALL AGES AND PROFESSIONS ADMITTED

Oklahoma Osteopathic Association PRODUCTION

Oklahoma D.O. | January 2014

WEDNESDAY, APRIL 23 9:00 NOON5:00 8:3010:00

OOA/OEFOM Golf & Tennis Tournament Oak Tree Country Club, Edmond, Oklahoma Convention Registration: Norman Embassy Suites Presidential Reception Honoring OOA President Bret S. Langerman and First Lady DeLaine Langerman 8:009:00

114th Annual

s le track du e h c s IALTY

SPEC

THURSDAY, APRIL 24 11:00NOON NOON2:00

2:003:30

10:0011:00

OPENING SESSION: V. Burns Hargis, President, OSU LUNCH WITH EXHIBITORS OOA ANNUAL BUSINESS MEETING Presiding: Bret S. Langerman, DO

ACOFP UPDATE Presiding: Ryan Schafer, DO, President,

Oklahoma Society ACOFP Special Guest: Duane G. Koehler, DO, FACOFP, ACOFP Board of Governors

OKLAHOMA HOUSE OF DELEGATES MEETING

Oklahoma D.O. | March January2014 2014

Oncology Track Importance of Integrative Oncology

Lorenzo Cohen, PhD (Professor and Director of the Integrative Medicine Program, Houston, TX)

Complementary Individual Medicine

Katherine Anderson, ND, FABNO (naturopathic medicine, Tulsa, OK)

PAGE 155

4:305:30

9:0010:00

Oklahoma D.O.

3:304:30

& 0 1 ICD ician Physrsement u b m i Re

Anesthesiology 114th Annual

s trackhedule Y sc

T SPECIAL

FRIDAY, APRIL 25

8:009:00 9:0010:00

10:0011:00

11:00NOON

NOON2:00 2:003:00

Oklahoma D.O. PAGE 256

3:004:00

4:005:00

Emergency Medicine

Internal Medicine

MORNING SESSION: “Interventional Pain Management: The Basics”

“Not Just for Kids Anymore! Intraosseous Vascular Access in the Emergency Department-Use of the Humeral IO in Adult Patients”

“Medical Certiﬁcation of Airmen with Coronary Artery Disease, Valve Replacement and Atrial Fibrillation”

Larry D. McKenzie, DO (certiﬁed pain management, anesthesiology, Tulsa, OK)

Justin W. Fairless, DO, FAAEM (certiﬁed emergency medicine, Tulsa, OK)

Warren S. Silberman, DO, MPH (certiﬁed preventative medicine, internal medicine & aviation/ aerospace medicine, Oklahoma City, OK)

“Perioperative Diabetes Management: The Ups and Downs”

“Emergency Medicine in the Boonies”

“Asthma Update”

Neal W. Siex, DO (certiﬁed anesthesiology, Tulsa, OK)

Arthur G Wallace Jr., DO, MPH, FACEP (certiﬁed emergency medicine, Jenks, OK)

Thomas W. Allen, DO, MPH, FACP, FCCP (certiﬁed internal medicine, sports medicine & pulmonary medicine, Tulsa, OK)

“Post Pain Control By Use of Regional Blocks and Pain Pumps”

“The Freestanding Emergency Department: Fad or The Wave of the Future!”

“Considerations and Evaluation of the Preoperative Patient”

Dale Derby, DO (certiﬁed anesthesiology & family practice, Owasso, Oklahoma)

Chad E. Borin, DO (certiﬁed emergency medicine, Oklahoma City, OK)

Melinda R. Allen, DO, FACOI (certiﬁed internal medicine, Blackwell, OK)

LUNCH PROGRAM: “The Obese Anesthesia Patient and Obesity Surgery”

“Hypothermia Treatment Post Cardiac Arrest”

“Calcium Disorder”

Brian T. Harris, DO (certiﬁed anesthesiology, Tahlequah, OK)

Timothy A. Soult, DO (certiﬁed emergency medicine, Oklahoma City, OK)

Henry M. Allen, DO (certiﬁed internal medicine & nephrology, Oklahoma City, OK)

“PreOp Eval - What Anesthesia Wants to Know and Why. What’s It’s Worth to You”

“Alternative Airway Management”

“New Developments in Diabetes”

Daniel P. Kite, DO (certiﬁed emergency medicine, Oklahoma City, OK)

Kenan L. Kirkendall, DO (certiﬁed internal medicine, family medicine & pediatrics, Woodward, OK)

“Basic Perspectives on Disasters”

“Update on Adult Exercise Guidelines & Weight Management”

David E. Hogan, DO (certiﬁed emergency medicine, Oklahoma City, OK)

Stephanie J. Husen, DO (certiﬁed internal medicine, pediatrics & sport medicine, Edmond, OK)

Ronald S. Stevens, DO (certiﬁed anesthesiology, Muskogee, OK)

“Perioperative Evaluation and Treatment of the Cardiac Patient for Non-cardiac surgery” Jay D. Cunningham, DO (certiﬁed anesthesiology, Oklahoma City, OK)

Oklahoma D.O. | March January2014 2014

OBGYN

Oncology

OMT

Neurology/ Psychiatry

Treating the Whole Patient with Trauma Osteopathically

“Breast Cancer: Screening, Prevention, Diagnosis“

“Exercise Prescription for Low Back Pain”

“Clinical Neuro Anatomy Review for the Practicing Physician”

Marvin Williams, DO, FACOG (certiﬁed in Maternal Fetal Medicine and Obstetrics & Gynecology, Oklahoma City, OK)

Pamela Crilley, DO (certiﬁed Oncology & Internal Medicine, Philadelphia, PA)

Mark H. Thai, DO (certiﬁed OMM & family practice, Tulsa, OK)

Jay K. Johnson, DO (certiﬁed neurology, Tulsa, Oklahoma)

“Drop-in Prenatal Liability: Tag You’re It”

“Pulmonary Nodules”

“Basic Science for Alleviation of Chronic Musculoskeletal Pain”

“Migraine, Spells, & Medication Overuse”

Joseph R. Johnson, DO (certiﬁed obstetric & gynecological surgery, Tulsa, OK)

Daniel A. Nader, DO, FCCP, FACP (certiﬁed Pulmonary Medicine and Internal Medicine, Tulsa, OK)

Robert Irvin, DO (certiﬁed OMM, Fort Worth, TX)

David Lee Gordon, MD, FAAN, FANA, FAHA (certiﬁed neurology & vascular neurology, Oklahoma City, OK)

“Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction”

“Cervical / Ovarian Cancer “

“Basic Science for Alleviation of Chronic Musculoskeletal Pain Lab”

“Women’s Issues in Epilepsy”

Elizabeth K. Harris, DO (certiﬁed obstetrics & gynecology, Tahlequah, OK)

Tashanna K.N. Myers-Gibson, MD, FACOG, FAAHPM (certiﬁed obstetrics & gynecology, gynecologic oncology and hospice and palliative medicine, Springﬁeld, Massachusetts)

Robert Irvin, DO (certiﬁed OMM, Fort Worth, TX)

Andrea S. Hakimi, DO (certiﬁed neurology & clinical neurophysiology, Oklahoma City, OK)

AOA Update & MOL/OCC

Robert S. Juhasz, DO (certiﬁed internal medicine, Warrensville Heights, OH)

“Differential Diagnosis of Dementia”

Bryan C. Roehl, DO, FACOOG (certiﬁed obstetrics & gynecology, Ada, OK)

Timothy Holder, MD, FAAFP (Oncology & Internal Medicine, Tulsa, OK)

Kelley J. Joy, DO (certiﬁed OMM & family practice, Tulsa, OK)

Jimmie D. McAdams, Jr., DO (certiﬁed psychiatry, Tulsa, OK)

“An Overview of Quality Initiatives in Women’s Health: The Paradigm Shift from Fee for Service to Value Based Purchasing”

“Genetics”

“Practical OMT: Demonstrating High-Yield Techniques For a Busy Family Practice”

“Movement Disorders- When to Refer?

Guy W. Sneed, DO, MBA, FACOOG, C-HCQM (certiﬁed obstetric & gynecological surgery, Tulsa, OK)

Michael A. Kayser, DO, FACMG, John L. Owens, DO (certiﬁed FAAP (Certiﬁed Medical Genet- OMT & family practice, Pryor, ics & Pediatrics, Tulsa, OK) OK)

Cherian A. Karunapuzha, MD (certiﬁed neurology, Oklahoma City, OK)

Urinary incontinence”

“Precision Medicine”

“Clinical Applications of Transcranial Doppler Ultrasound”

Diane Evans, DO, MS, FACOOG, FACOG (certiﬁed obstetrics & gynecology Walnut, MS)

Maurie Markman, MD (certiﬁed Internal Medicine, Medical Oncology, Hematology, Philadelphia, PA)

OMT Workshop

Ryan K. Hakimi, DO (certiﬁed neurology , Oklahoma City, OK)

PAGE 357

“Making OMM Work in a Primary Care Setting”

Oklahoma D.O.

“Comorbidities and Cancer Management”

AFTERNOON SESSION

“What’s New in Prenatal Screening”

Oklahoma D.O. | March January2014 2014

MORNING SESSION

“Amniotic Fluid Abnormalities”

Anesthesiology 8:009:00 9:0010:00

10:0011:00

11:00NOON

Oklahoma D.O. PAGE 458

SATURDAY, APRIL 26

114th Annual

SPECI

s trackhedule ALTY sc

3:004:00

4:005:00

Internal Medicine

MORNING SESSION: Anesthetic Considerations in Chronic Pain Patients”

“So When the DEA Calls.....”

“Incorporating Mental Health into Internal Primary Care”

Daniel G. Morris, DO (certiﬁed pain management, anesthesiology, Tulsa, OK)

Jerry C. Childs, Jr., DO (certiﬁed emergency medicine, Oklahoma City, OK)

Thomas D. Schneider, DO (certiﬁed internal medicine, Tahlequah, OK)

Labor Anesthesia”

“Sepsis-Presenting to the ER”

“Caution: DMARD Zone”

Michael J. Major, DO (certiﬁed anesthesiology, Oklahoma City, OK)

Billy R. Bryan, DO, FACEP (certiﬁed emergency medicine, Oklahoma City, OK)

Debbie A. Gladd, DO (certiﬁed internal medicine & Rheumatology, Tulsa, OK)

“Postop Cognitive Decline”

“Oklahoma’s Native Dangers”

“Pulmonary Evaluation Revisited”

Ty A. Martindale, DO (certiﬁed anesthesiology, Oklahoma City, OK)

Kristopher K. Hart, DO, FACOEM (certiﬁed emergency medicine, Oklahoma City, OK)

James S. Seebass, DO (certiﬁed pulmonary medicine & internal medicine, Tulsa, OK)

NOON1:30 1:302:00 2:003:00

Emergency Medicine

LUNCH PROGRAM: “What Are In Anesthesia Infuriation Management System and How do I get me one?”

“Forensic Medicine in the ER: Helping the Police Investigators”

“The Physicians Prescription for Nutrition”

Ronald S. Stevens, DO (certiﬁed anesthesiology, Muskogee, OK)

Larry T. Lovelace, DO, FACEP (certiﬁed emergency medicine, Oklahoma City, OK)

Michele L. Neil, DO (certiﬁed internal medicine & sports medicine, Tulsa, OK)

“Neuro Trauma”

“EHR’s in the ER, The Good, Bad, and Ugly”

“Chronic Kidney Disease”

John B. Hill, DO (certiﬁed anesthesiology Norman, OK)

Gregory H. Gray, DO (certiﬁed emergency medicine, Tulsa, OK)

Beverly J. Mathis, DO (certiﬁed nephrology & internal medicine, Tulsa, OK)

“Emergency Management of Atrial Fibrillation”

“New Cholesterol Updates”

James B. Williams, DO, FACOEP (certiﬁed emergency medicine, Oklahoma City, OK)

Natasha N. Bray, DO (certiﬁed internal medicine, Fort Lauderdale, FL)

Oklahoma D.O. | March January2014 2014

OBGYN

Oncology

OMT

Neurology/ Pediatrics Psychiatry

Treating the Whole Patient with Trauma Osteopathically

“Recurrent Pregnancy Loss”

“Prostate Cancer “

“Foot Treatment”

Lecture Title

Diane Evans, DO, MS, FACOOG, FACOG (certiﬁed obstetrics & gynecology Walnut, MS)

Douglas Kelly, MD ( boardcertiﬁed radiation oncologist, Tulsa, OK)

Michael K. Cooper, DO, FACOFP (certiﬁed OMM & family practice, Tulsa, OK

Nicole M. Willis, DO (certiﬁed pediatric, Vinita, OK)

“The Short Cervix”

“Communicating with the Cancer Patient”

“OMT Practicum - Neck and Upper Thoracic Dysfunctions.”

“Apply Osteopathic Principles to the Structural Exam of a Developing Child”

“Ofﬁce Based Evaluation and Management of Concussion”

Marvin Williams, DO, FACOG (certiﬁed in Maternal Fetal Medicine and Obstetrics & Gynecology, Oklahoma City, OK)

Carol Dillard, PhD, LPC, LMFT

Robin R. Dyer, DO (certiﬁed OMM & family practice, Tulsa, OK)

Lisa E. Hart, DO (certiﬁed pediatric, Tulsa, OK)

Gabriel M. Pitman (certiﬁed Neurology, Oklahoma City, OK)

OSU-COM UPDATE ALUMNI MEETINGS

“Child Abuse and Neglect”

“Psych 101: How to Address the Psychiatric Needs of Your Patients in an Family Practice Setting”

Jeffrey M. Hunt, DO (certiﬁed Internal Medicine, Tulsa, OK)

Robert Irvin, DO (certiﬁed OMM, Fort Worth, TX)

Sarah J. Passmore, DO (certiﬁed pediatric, Tulsa, OK) and Michael A. Baxter, DO (certiﬁed pediatric, Tulsa, OK)

W. John Mallgren, DO (certiﬁed psychiatry, Claremore, OK)

“Method for Alleviation of Chronic Musculoskeletal Pain Lab”

Draion M. Burch, DO, FACOOG (certiﬁed obstetrics & gynecology, Pittsburgh, PA)

Robert Irvin, DO (certiﬁed OMM, Fort Worth, TX)

Lecture Title

“Making Sense of Clinical Osteopathy: Functional Pathways to Recognition of Disease”

“Pediatric Concussion Assessment & Management”

Jay M. Williamson, DO (certiﬁed obstetrics & gynecology, Tulsa, OK)

Barry S. Rodgers, DO (certiﬁed Neuromusculoskeletal medicine & OMM, Oklahoma City, OK)

Stephanie J. Husen, DO (certiﬁed pediatrics, internal medicine & sports medicine, Edmond, OK)

Oklahoma D.O. | March January2014 2014

“Rural Psychiatry/Telepsychiatry and The Future”

Vincel R. Cordry, Jr., DO (certiﬁed psychiatry, Oklahoma City, OK) “A Review of the Newer Oral Anticoagulants and Reversal Strategies” Ryan K. Hakimi, DO (certiﬁed neurology and Neurosonology, Oklahoma City, OK)

PAGE 559

“The “L- Word”- Lesbian Health AND “T-Talk”-Transgender Health”

Oklahoma D.O.

“Method for Alleviation of Chronic Musculoskeletal Pain”

AFTERNOON SESSION

“Colorectal”

MORNING SESSION

Ronnie B. Martin, DO, FACOFP, dist (certified family practice, Blacksburg, VA); Amanda D. Martin, DO (orthopedic surgery, Birmingham, AL); and Natasha Martin-Bray, DO (certified internal medicine, Fort Lauderdale, FL) “Endometriosis Treatment” “Skin Cancer” Buns of Steel “Childhood Obesity Buns of Still Identification and Treatment” “Puns of Still: Similes, Analogies, and Metaphors: Explanation of OMT Techniques for Patient “Prevention of Stroke: TreatUnderstanding and Enjoyment” ment of Acute Ischemic Stroke & Treatment of Hemorrhage/ R. Troy Lehman, DO, FACOOG Peter M. Knabel, DO Constance G. Honeycutt, Brian K. Lepley, DO (certified Aneurysm” (certified obstetrics & gynecolDO (certified OMM, addictive pediatric, Oklahoma City, OK) ogy, Woodward, OK) diseases & family practice, Glenpool, OK) Charles Morgan, MD

SUNDAY, APRIL 27 7:0010:00

10:0011:00

AOA CO*RE Rems Program

Thomas F. Jan, DO, FAOCPMR (certiﬁed physical medicine & rehab, Massa[equa, NY) & Daniel G. Williams, DO (certiﬁed Neuromusculoskeletal Medicine and Osteopathic Manipulation, Indianapolis, IN)

Opioid Prescribing Guidelines forOklahoma Health Care Providers in the Office-Based Setting Proper Prescribing Course-Sign in Required

Layne E. Subera, DO, FACOFP (certiﬁed family practice, Skiatook, OK)

11:00 1:00

Medical Protective Program

Gail Harris, Senior Risk Consultant (Clinical Risk Management, Vegas, NV)

annual convention activities

HOTEL RESERVATIONS

SeekingSitters

For hotel accommodations, please contact Wendy at Embassy Suites Norman - Hotel and Conference Center at 405-253-3547.

Oklahoma D.O. PAGE 660

Standard Suite is $145.00 a night. Check in: 3:00 pm/ Check out: 12 Noon. To avoid cancellation charges, reservations should be cancelled by 3:00 pm Room Cut-off is March 23, 2014 Room Amenities include: Two 32” televisions , Two phone lines with voicemail and data ports, Wireless Internet access, Hospitality center with microwave, refrigerator, and coffee maker. Don’t forget to mention you are with the OOA!

PRE-REGISTRATION is greatly appreciated! register online or on the convention form on page 13

Oklahoma D.O. | March January2014 2014

Oklahoma Osteopathic Association’s 114th Annual Convention April 24-27, 2014 Embassy Suites Norman - Hotel and Conference Center 2501 Conference Drive, Norman, OK 73069 Full name: _____________________________________________________________________________________________________________________ Preferred Name / ﬁrst name for name badge: __________________________________________________________________________________________ Ofﬁce address: _________________________________________________________________________________________________________________ City: ____________________________________________________________________ State: ____________________ Zip: _____________________ Email: _______________________________________________________ Phone: ________________________________________________________ OTHER NAME BADGES NEEDED FOR:

check the box, if you plan to register this child in SeekingSitters

Spouse: ___________________________________________________________________________________ Guest(s): __________________________________________________________________________________ Children/Teens : 

(age)



(age)



(age)

NOTE: All convention registrants, Teens, Children, and Guests MUST wear an OOA name badge to enter the exhibit hall. We suggest listing all of your guests above to save you time during the registration process.       

On/Before April 17, 2014

DO Member Registration (or other AOA divisional society member) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $540 (Includes Sunday’s Proper Prescribing Lecture and Risk Management Program) Retired DO Member Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 DO Nonmember Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,090 Spouse/Guest/Exhibitor Events Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $220 MD and Non-Physician Clinicians Registration* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $540 Osteopathic Medical Student:  OMS-I  OMS-II  OMS-III  OMS-IV . . . . . . . . . . . . . . . . . . . . .$0 Intern  Resident  Fellow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $0

After April 17, 2014

$565

$325 $1,115 $245 $565 $0 $0

Registration is complimentary for osteopathic students and physicians in postgraduate training. They are welcome to attend all programs and convention functions at no charge. Please make event ticket requests at the OOA Registration desk. Badge required.

  

DO Member Registration for Sunday Program Only** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $195 DO Nonmember Registration for Sunday Program Only** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $745 MD and Non-Physician Clinician Registration for Sunday Program Only** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $195

$220 $770 $220



Non-registered OOA Members may purchase Banquet tickets. I would like to purchase ________ Banquet ticket(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75 each

$100 each

TOTAL AMOUNT DUE:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

$______________

Registration includes name badges(s), registration gift and all meals and social events unless otherwise noted. *Registration includes name badge, certiﬁcate, and registration gift. **Registration DOES NOT include registration gift or meal tickets. 

Charge my VISA, MASTERCARD, AMEX, DISCOVER:

Card #: ________________________________________________________________________________________________ Exp. Date:______________ Name (as it appears on card): _______________________________________________________________________________________________________ Billing Address: __________________________________________________________________________________________________________________ City: _______________________________________________________________ State: ___________________________ Zip: _______________________ 

My check in the amount of $______________ is enclosed and made payable to the Oklahoma Osteopathic Association.

Mail this form and payment to: Oklahoma Osteopathic Association: 4848 N Lincoln Blvd, Oklahoma City, OK 73105-3335 or FAX: 405-528-6102 NOTE: Due to the number of specialty tracks, a print syllabus will not be offered. A digital syllabus will be sent to registrants in advance for those wishing to print their own. All DO attendees must be members in good standing with their respective state association in order to attend at the announced fees. Otherwise, a DO may attend the convention by paying an additional $550, which may be applied towards OOA membership dues with completed application. Students, interns, residents, and fellows are not required to pay a registration fee and are welcome to attend all convention functions at no charge. Requests for refunds must be received before April 17, 2014, and a $45 service fee will be charged. NO REFUNDS AFTER APRIL 17, 2014.

Classified Advertising OFFICE FOR RENT: 1,500 square feet in an excellent area with high traffic count. Established location. Completely remodeled, very nice. Easy access from all areas of town, 7300 S Western, OKC. Rent is $1250 per month with all utilities paid. Please call Dr. Buddy Shadid 405.833.4684 or 405.843.1709. OFFICE BUILDING FOR SALE: 6501 S. Western, OKC, OK 73139. Over 1 1/2 acres total size, 10,000 sq ft building divided into 3 doctors offices. 1200 sq foot private office upstairs with private bathroom and shower. 2 double sided fireplaces, over a dozen chandeliers, rough wood cathedral ceilings. Alarm and phone system in place, double glass doors in entrance, back patio with separate storage building. Larger office is fully equipped with exam tables, Pap table, chairs, medical instruments, QBC (CBC) machine, autoclave, medical supplies, and much more. For information contact: Captain David Simpson at (405) 820-5360.

Oklahoma D.O. PAGE 62

CLINIC FOR SALE: By owner. Fully equipped: LAB, XRAY, EKG. Well established clinic, near Integris Southwest Medical Center is available for sale. Clinic is well equipped and is ideal for one or more physician practice as well as a variety of specialties. Clinic has: waiting room with refrigerated water cooler, wheelchair accessible restroom, reception and staff work stations, Nurses station, 5 - 7 exam rooms with sinks and running water, large multipurpose procedure room, 3 private offices with built-in bookcases, (One Office with 3/4 Bath), additional staff and patient restrooms, large upstairs (currently used for storage) and variety of other medical equipment. Misys Medical Software. Large Parking Lot. “Must See Inside” the all steel building located at 2716 S.W. 44th St. in OKC to appreciate the effort placed upon providing convenient and up to date medical care. PRICE IS NEGOTIABLE. Doctor prefers to sell, but would consider leasing. If interested, please call: Evelyn Francis at (405) 249-6945.

STAFF PHYSICIAN NEEDED: The Oklahoma Department of Corrections is seeking applicants for Staff Physician at our correctional facilities statewide. The state of Oklahoma offers a competitive salary and benefits package which includes health, dental, life and disability insurance, vision care, retirement plan, paid vacation, sick days, holidays and malpractice insurance coverage. For more information and a complete application packet contact: Becky Raines 2901 N. Classen Blvd., Suite 200 Oklahoma City, OK 73106-5438 (405) 962-6185 FAX (405) 962-6170 e-mail: braines@doc.state.ok.us DOCTORS WANTED: to perform physical exams for Social Security Disability. DO’s, MD’s, residents and retired. Set your own days and hours. Quality Medical Clinic-OKC, in business for 16 years. Call Jim or JoAnne at 405-632-5151. PHYSICIAN NEEDED: The practice of Terry L. Nickels, DO is currently seeking a part-time Family Physician with OMT Skills to help cover the office. If interested please contact Dr. Terry Nickels at (405) 301-6813. Family, Urgent Care, and Emergency Practitioners – Immediate Opportunities for FT/ PT and temp positions. Oklahoma physician owned placement company is hiring now. Offering top wage, flexible schedules, paid malpractice and travel expenses. Call Rachelle at 877-377-3627 or send CV to rwindholz@oklahomaoncall. com

IMMEDIATE OKLAHOMA OPPORTUNITY with largest family medicine clinic in Muskogee, Ok. Excellent opportunity to assume a practice that is up and running. Senior physician of four physician group leaving to pursue new career opportunities. 2,000 active patients need a physician. Two physicians currently practice OB. Surgical OB experience a plus. On site x-ray and CLIA certified lab. Nursing and support staff in place. Income guarantee. Be your own boss, work hard and practice family medicine in its historical tradition with respect and loyalty of small town patients. Contact Evan Cole, DO, 918-869-2456, ecoledo@yahoo.com, Brad McIntosh, MD, 918-869-7356, drbamc@yahoo.com Jason Dansby, MD, 918-869-7387, jasonddansby@yahoo.com or Judy Oliver, RN, practice administrator, 918-869-7357. (leave a message if temporarily unavailable) Find us on the web at www.mfpclinic.com. Oklahoma D.O. | January 2014

E T A HE D

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Oklahoma D.O.

March 6, 2014 DO Day at the Capitol in Washington DC

April 10, 2014 Southwestern District Meeting/CME (Lawton)

PAGE 63

Oklahoma D.O. | January 2014

Prsrt Std US Postage Paid Okla City OK Permit #209

OKLAHOMA OSTEOPATHIC ASSOCIATION 4848 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105-3335

RELATIONSHIPS YOU CAN RELY ON PROTECTING YOUR MEDICAL PRACTICE FOR 83 YEARS

The Oklahoma Osteopathic Association has endorsed Rich & Cartmill, Inc. and Medical Protective since 1999 Please support your OOA and consider Rich & Cartmill, Inc. for your Professional Liability Insurance needs.

Oklahoma D.O. PAGE 64

For more information contact Scott Selman at 918-809-1461 or sselman@rcins.com

2738 E 51st Street, Suite 400 | Tulsa, OK 74105-6228 | 918.743.8811 | www.rcins.com

TULSA

OWASSO

OKLAHOMA CITY

SPRINGFIELD, MO Oklahoma D.O. | January 2014