June 2016 | Physician Magazine by Los Angeles County Medical Association

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A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

LACMA’S NEW INNOVATORS SERIES FEATURING

Emil Avanes, MD JUNE 2016

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See the L.A. artists you’ll be hearing about. Don’t miss Made in L.A. 2016: a, the, though, only The third iteration of the Hammer Museum’s biennial exhibition continues to highlight the work of emerging and under-recognized artists in the Los Angeles area. The exhibition will run June 12 – August 28. The museum is always free. Made in L.A. is presented by Wells Fargo. For more information, visit hammer.ucla.edu/made-in-la-2016/.

JUNE 2016 | TA B LE OF CONT ENT S

O F F I C I A L P U B L I C AT I O N O F T H E L O S A N G E L E S C O U N T Y M E D I C A L

A S S O C I AT I O N

Volume 147 Issue 6

10 COVER STORY

FEATURE

Confronting the Opioid Crisis

Physicians are on the front lines of the opioid epidemic and to provide more understanding of the issues and potential legal implications, experts and local providers offer expertise and insight on new guidelines from the CDC and Medical Board of California, prescribing tips and CURES 2.0.

INNOVATORS SERIES EMIL AVANES, MD

10 The Rise and (Eventual) Fall of Opioids

FROM YOUR ASSOCIATION 4 President’s Letter | Peter Richman, MD 6 Why Does LACMA Exist? | Gustavo Friederichsen

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine,801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Advertising rates and information sent upon request.

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EDITOR

Sheri Carr 858.226.7647 | sheri@physiciansnewsnetwork.com ADVERTISING SALES

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The Los Angeles County Medi-

Physicians News Network Los Angeles County Medical Association 801 S. Grand Avenue, Suite 425 Los Angeles, CA 90017 Tel 213.683.9900 | Fax 213.226.0350 www.physiciansnewsnetwork.com

cal Association is a professional association representing physicians from every medical

LACMA OFFICERS

specialty and practice setting PRESIDENT

as well as medical students, interns and residents. For more

Christina Correia 213.226.0325 | christinac@lacmanet.org Dari Pebdani 858.231.1231 | dpebdani@gmail.com David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

PRESIDENT-ELECT

TREASURER SECRETARY

IMMEDIATE PAST PRESIDENT

Peter Richman, MD Vito Imbasciani, MD William Averill, MD Richard Baker, MD Pedram Salimpour, MD

than 100 years, LACMA has LACMA BOARD OF DIRECTORS

been at the forefront of current medicine, ensuring that its members are represented in the

CMA TRUSTEE

ALTERNATE RESIDENT/FELLOW COUNCILOR

COUNCILOR – SSGPF

COUNCILOR – DISTRICT 9 CMA TRUSTEE COUNCILOR

areas of public policy, govern-

COUNCILOR – DISTRICT 2

ment relations and community

ETHNIC PHYSICIANS COMMITTEE REP

relations. Through its advocacy

COUNCILOR – DISTRICT 17

COUNCILOR-AT-LARGE

efforts in both Los Angeles County and with the statewide California Medical Association, your physician leaders and staff strive toward a common goal– that you might spend more time treating your patients and less

COUNCILOR – DISTRICT 1

COUNCILOR – DISTRICT 14 COUNCILOR – USC

COUNCILOR – DISTRICT 7 COUNCILOR – DISTRICT 6 COUNCILOR-AT-LARGE

COUNCILOR – ALLIED PHYSICIANS COUNCILOR-AT-LARGE

COUNCILOR – DISTRICT 3

COUNCILOR – DISTRICT 10

MEDICAL STUDENT COUNCILOR/USC

COUNCILOR – SCPMG

RESIDENT/FELLOW COUNCILOR

YOUNG PHYSICIAN COUNCILOR

COUNCILOR-AT-LARGE

COUNCILOR – SSGPF

ALT. MEDICAL STUDENT COUNCILOR/UCLA

time worrying about the chal-

COUNCILOR-AT-LARGE

CHAIR OF LACMA DELEGATION

David Aizuss, MD Erik Berg, MD Robert Bitonte, MD Stephanie Booth, MD Jack Chou, MD Troy Elander, MD Hilary Fausett, MD Samuel Fink, MD Hector Flores, MD C. Freeman, MD Sidney Gold, MD Jinha Park, MD Stephanie Hall, MD David Hopp, MD Kambiz Kosari, MD Sion Roy, MD Paul Liu, MD Maria Lymberis, MD Philip Hill, MD Nassim Moradi, MD Vamsi Aribindi Ashish Parekh, MD Jerry Abraham, MD Po-Yin Samuel Huang, MD Michael Sanchez, MD Heather Silverman, MD Annie Wang Nhat Tran, MD Fred Ziel, MD

lenges of managing a practice. LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

SUBSCRIPTIONS Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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P RES IDEN T ’S LET T ER | P ET ER RIC H M AN, M D

“...Physicians have differing political and social perspectives. We need to have honest discussions as to the problems and accept differing opinions. We need to reach common ground if we are to solve the difficult issues facing medicine.”

I A T T E N D E D T H E Western Health Care Leadership Academy in May. The conference, cosponsored by the CMA, Texas Medical Association and The Physicians Foundation brought together county and state medical executives and physician leaders from several states to discuss a multitude of current issues affecting medicine. The current state of medicine is in flux, with many unknowns. Obamacare (the Patient Protection and Affordable Care Act) was enacted in 2010, but we are only now seeing the full implementation of its myriad regulations. The SGR (Sustainable Growth Rate) was eliminated but replaced with MACRA (Medicare Access and CHIPS Reauthorization Act) in 2015. The effects of this bill will roll out over six years. Two speakers addressed the state of the union with regard to healthcare: Karl Rove and Donna Brazile. Mr. Rove was the deputy chief of staff and senior advisor to President George W. Bush. Ms. Brazile was campaign manager for Al Gore and vice chair for the Democratic National Committee. Prior to Obamacare, there was a burgeoning healthcare crisis. Medical inflation was significantly outpacing the consumer price index. The middle class was losing its access to medical insurance due to cost. Switching to lower-cost insurance was not always possible. The market had limited choices, and insurance companies were excluding new enrollees based on preexisting illness, very loosely defined. One friend of mine was unable to obtain insurance for his son due to a hip pinning as an adolescent despite the fact the young man was playing high school volleyball. Those with insurance ran the risk of being retroactively dis-enrolled if they had an expensive illness and had not filled out complex forms correctly. There were lifetime benefit limits that were reached with major traumas or cancer care. In addition, there were over 50 million uninsured people in the wealthiest nation on earth ever! President Obama and the Democratic Party took political advantage of the situation and rapidly passed the Affordable Care Act prior to losing

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control of Congress. There was not a full vetting of the bill, and much was left to be determined by HHS (United States Department of Health and Human Services) and CMS (Centers for Medicare and Medicaid Services). Obamacare met some of its objectives. Millions of patients without previous insurance became insured. The acceleration of medical inflation slowed. Preexisting illness was no longer precluding one from obtaining insurance. Because of this, those with insurance could not be retroactively denied. Family insurance was expanded to cover children to age 26 (millennials not leaving home). Obamacare has not met all of its objectives. Many with insurance were switched to a lesser plan without access to their established physician. Also, many with insurance cannot find a doctor willing to see them. Access remains a large problem. Medical inflation continues to outpace overall inflation, and steep rises in insurance are expected in the next one to two years. Some large insurers are pulling out of the exchange market altogether. High deductibles preclude many families from using medical services except for catastrophic illness or trauma. Clearly Obamacare will need major changes if it remains. Hillary Clinton will support Obamacare; Donald Trump may not. There has not yet been a significant Republican alternative put forth that will deal with the poor not having insurance otherwise. MACRA is independent of Obamacare and had the overwhelming support of both parties. Overturning this would be highly unlikely. The most amazing aspect of the discussion between Karl Rove and Donna Brazile was the civility and friendship of the two. In today’s political climate, one would expect name-calling, dismissiveness and interruption from two polar opposites on the political spectrum. Quite the contrary, they were respectful, joking and self-deprecating. There was honest discussion with an acceptance of differing opinions. They both agreed that each was concerned for the good of the nation and they were Americans first, Republican and Democrat second. In the same light, physicians have differing political and social perspectives. We need to have honest discussions as to the problems and accept differing opinions. We need to reach common ground if we are to solve the difficult issues facing medicine. As my tenure as president of LACMA comes to an end, I want to thank you for allowing me to serve you for the past year.

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WHY DOES L ACMA EXIST?

This is the

question I pose to each of you and will address in our 2016 Strategic Planning Session on June 11. While we have a rich and diverse history, spanning 145 years, we are still relatively unknown. How is this possible?

“Change will only come after we come together, understand what is at stake and embrace our new normal. Then we can finally accomplish our mission, achieve solidarity and become what the founders envisioned.“

The largest county in the state of California with the largest number of physicians, numbering almost 31,000, and yet our active membership is less than 8%. To be the trusted voice for physicians means we must move forward with an unprecedented shift in culture; we must deliver on every promise made, we must be more than relevant, we must embark on a new narrative while defending our vision, our mission and, yes, our reason for existence. Purpose is what I want each of our members to embrace, acknowledge and share. This one tenet is so essential to LACMA’s prosperity that I will continue to ask and to engage active and non-active members (and even detractors) on this one topic: Is our purpose relevant? Is our purpose just a word without true meaning? Has our most recent history eroded 140-plus years of impactful leadership? What role have you played or continue to play in demonstrating our purpose? Here are some thoughts on what I believe we can accomplish as an organization and redefine our purpose: We can stay focused on what’s important: To be the premier organization that all LA County physicians look to for their professional needs, that the healthcare community respects, and that the public trusts. To remain steadfast as a transparent, trustworthy organization of dedicated physicians who advocate quality healthcare for all patients and serve the professional needs of its members. And finally, to adhere to three simple values: Perseverance, Integrity and Excellence. I continue to hear from members. I’ve heard the good, the bad and the ugly. One particular physician, Dr. Emil Avanes, is an inspiration to his patients, family, colleagues and to me. For every criticism or concern, Dr. Avanes has a suggestion, a well-thought-out idea or solution. This is the hallmark of true leadership. This is why Dr. Avanes is featured this month as an “Innovator,” because he’s not just complaining about healthcare; he’s trying to fix it while redefining LACMA’s purpose. Healthcare is complex enough without the legislative threats that distract us, the economic battles Dr. Avanes and members face that impacts livelihoods and lives, or any internal disagreements members have. We must rise above all discord to recalibrate this organization. It won’t be easy. It won’t happen in a vacuum, and it most certainly won’t occur without purpose. Change will only come after we come together, understand what is at stake and embrace our new normal. Then we can finally accomplish our mission, achieve solidarity and become what the founders envisioned.

Gustavo Friederichsen Chief Executive Officer

6 P H Y S I C I A N M A G A Z I N E | J UN E 2016

THE STRENGTH TO HEAL

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I NN O VATOR S SE RIES | EM IL AVANES, MD Great organizations have great traditions. As part of our transition to the kind of organization that represents physicians and all that they do to improve health, change lives and impact communities, we’ve started the Innovators Series. The purpose is simple: to showcase innovation across a diversity of spectrums: medical practice, patient experience, embracing change, technology, entrepreneurship, collaboration and clinical advancements, to name a few. IF YOU WOULD LIKE TO NOMINATE AN “INNOVATOR,” EMAIL GUSTAVO FRIEDERICHSEN AT GUSTAVO@LACMANET.ORG.

When Emil Avanes, MD, founded his family practice, he envisioned a place where good, oldfashioned patient care would harmonize with the modern world of healthcare and technology. Seven years later, the innovative Harmony Health MD in Glendale has expanded into a twodoctor practice, soon to be three, and continues to draw patients who value its personal and highquality care, transparency and trusting relationship with the doctor and staff. Dr. Avanes, who is LACMA’s president of District 2, attributes his success to striving to create the ideal system based on the new principles established by the Affordable Care Act and government changes to reimbursement rather than trying to assimilate into another healthcare system. “We have created an office that has complete transparency,” he said. That is transparency not only in the vision statement, but also in the physical design of the office. When patients walk in, they aren’t put into a waiting room. 8 P H Y S I C I A N M A G A Z I N E | J UN E 2016

The office has no sliding glass doors that shut patients out. Rather, they’ll find natural light, open spaces and earth-tone colors on the walls to create a welcoming, friendly environment, he said. “We wanted to remove physical barriers between us and the patients,” he said. “That was the formulative foundation of our vision, that we are going to provide transparent service and give patients information regarding their health condition and answer insurance-related questions,” he said. Dr. Avanes said it’s no accident that on Yelp alone 68 out of 70 reviewers gave Harmony Health MD a five-star rating. Ensuring that patients receive high-quality medical care and delivering on their promises are values Dr. Avanes does not take for granted. He said while the office can’t always say exactly how much a particular service will cost a patient – given that fees are often dictated by insurers – he says when the office does give a patient a certain estimate, they stand behind it. “If we promise a test will cost $100 and it ends up costing $1,000, we don’t make the patient pay,” he said. Naturally, these situations are rare; otherwise a business wouldn’t be able to function

to be innovative to grow like and flourish, he noted, but they wildfire to establish our vihave earned patients’ respect “Our motto is to engage, sion in the community and and trust. garner support from other “Our motto is to engage, empower and enrich. When institutions to support our viempower and enrich,” he said. you have transparency, you sion.” “When you have transparency, “Dr. Emil Avanes is the you empower patients by givempower patients by giving epitome of a young physiing them the information they cian faced with a daunting need, and by doing these two, them the information they challenge: Get swept up you enrich people’s lives.” need, and by doing these two, in the tumultuous changes Dr. Avanes believes that’s in healthcare, or create a the innovative part of Harmony you enrich people’s lives.” unique offering for his paHealth MD – honoring traditients in his community,” tional values and transparency said LACMA CEO Gustavo in this new age world where Friederichsen. “His model patients are also more informed and do their research on such social platforms as Face- is part startup, part patient experience optimization and part entrepreneurial -- and 100% dedication. It’s taken book, Twitter and Instagram. Dr. Avanes also feels strongly that his team of seven more than blood, sweat and tears but a leap of faith that employees augments his practice. Every single employ- started when he came to this country decades ago.” ee was carefully picked to ensure the practice delivers the best services and care. “They are unique in that they have reversed every stereotype.” He said his team is approachable and caring – to the point where they will spend hours on the phone to get authorizations – and they get things done. They also embody the values of MEDICAL PRACTICE PURCHASES, SALES AND MERGERS Harmony Health MD: hope, unity, compassion and excellence. Hope, Dr. Avanes said, means not giving up; unity means everyone will put their differences aside to work together; compassion and excellence, of course, speak for themselves. Providing high-quality care and delivering the best outcomes without wasting money, he said, is what Assisting physicians with the Affordable Care Act is based on. Harmony Health MD recognized this legal issues for over three decades. principle ahead of its time. In that Fenton Law Group, LLP sense, the young physician said, his 1990 South Bundy Drive practice runs like a startup. Suite 777 “Every time there is a new comLos Angeles, CA 90025 The brand physicians trust 310.444.5244 pany established, the indicator of sucwww.fentonlawgroup.com cess is growth,” he said. “We are like a dot com startup company and need

MEDICAL BOARD HOSPITAL STAFF F R A U D / A B U S E MEDI-CAL/M E D I C A R E

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T H E RIS E AN D (EVEN T U AL) FALL OF OP IOIDS

SAFE MED LA:

The Rise and (Eventual) Fall of Opioids GARY TSAI, MD, CO-CHAIR, SAFE MED LA, MEDICAL DIRECTOR AND SCIENCE OFFICER SUBSTANCE ABUSE

PREVENTION AND CONTROL COUNTY OF LOS ANGELES, DEPT OF PUBLIC HEALTH | GTSAI@PH.LACOUNTY.GOV

Prescription drug abuse has become one of the fastest growing public health concerns in the United States and a popular topic on campaign trails and in the media. Years of unimpeded opioid prescribing by physicians has contributed to a national epidemic of addiction, worsened health outcomes, and overdose deaths. Alarmingly, drug overdoses have surpassed motor vehicle accidents as the leading cause of injury deaths in the U.S. In Los Angeles County, there have been approximately 400 reported opioid-related deaths/year; however, this number is likely an underestimate of actual deaths and does not include overdoses and near deaths. Recent outbreaks of fentanyl-related deaths in Northern California this April are a reminder that this issue touches individuals of diverse cultural and socioeconomic backgrounds. Physicians play a critical role in combating the current opioid epidemic. For this reason, the Substance Abuse Prevention and Control, a division of the Los Angeles County Department of Public Health, helped to establish Safe Med LA and encourages physicians and other health professionals to join (SafeMedLA.org). Safe Med LA is a countywide coalition of health professionals dedicated to taking a multifaceted approach to reduce prescription drug abuse and overdose deaths. The work of the coalition includes priority-specific Action Teams focused on safe prescribing guidelines, expanding access to naloxone, and medication-assisted addiction treatments such as buprenorphine and long-acting injectable naltrexone. Additional areas of focus are safe drug disposal, CURES utilization, pharmacy practice, community education, law enforcement, and data collection. Leveraging the collective impact of this continuum of interventions to target key pressure points of opioid misuse, Safe Med LA is using a “blanket” strategy to avoid the scenario that often

While the U.S. comprises just 5% of the global population, it uses 80% of the world’s opioids.

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arises when addressing complex problems – the ballooning and worsening of certain aspects of a problem while resolving others. This is where the medical community can help. While the U.S. comprises just 5% of the global population, it uses 80% of the world’s opioids. As much as anything, addressing the opioid crisis will require a culture change in how society views pain. Physicians and other healthcare professionals shape our community’s perspective on how best to respond to pain, and what to do when our reliance on painkillers becomes problematic. For years now, we have elevated our focus on pain and conveyed to communities that pain should not to be tolerated. We now know that this message has contributed to the overuse and misuse of painkillers, and realize the need to reframe the goal of chronic pain management to one of “functional tolerance” as opposed to “zero pain.” Physicians also play an important role in helping individuals acknowledge opioid addiction and seek help, when necessary. By joining Safe Med LA Action Teams, physicians can be an active part of the solution to the ongoing opioid epidemic. All interested physicians are encouraged to join Safe Med LA by visiting SafeMedLA.org. In addition, please join the Los Angeles Health Alert Network (LAHAN) to receive public health notifications such as the recent FentanylContaminated Street Norco. In this Drug Overdose Health Alert, LA physicians were alerted to recent deaths in Northern California and provided information on reporting suspected and confirmed fentanyl overdoses in LA County. To view this alert and to join LAHAN, visit publichealth. lacounty.gov/lahan.

Join the

LOS ANGELES HEALTH ALERT NETWORK Do you want to be notified about public health threats such as Zika or tainted opioid products? Do you want to receive authoritative information about infectious diseases that may affect your patients?

JOIN LAHAN TO STAY INFORMED! The Los Angeles County Department of Public Health communicates important public health information to health care professionals in Los Angeles County through the Los Angeles Health Alert Network (LAHAN).

All Los Angeles physicians are encouraged to join LAHAN to improve communication during public health emergencies. LAHAN sends health alerts, advisories, and updates on topics such as disease outbreaks, emerging infectious diseases, immunizations, drug shortages and recalls. There are, on average, only 1-2 communications a month and the urgency and target audience are clearly marked. For more information and to see archived LAHAN communications, visit publichealth.lacounty.gov/lahan

Please join this important network. It is a valuable resource to help you serve your patients and to protect the health of the Los Angeles community.

publichealth.lacounty.gov/lahan Sign up takes less than 2 minutes. Your contact information will not be shared and you can unsubscribe at any time. J UN E 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 11

CONFRONTING THE CRISIS BY MARION WEBB

Opioid and pain management perceptions, practices and recommendations have changed dramatically over the past few years, and several high-profile addictions and deaths have generated heavy media coverage in recent months and have heightened government concerns and actions. The Medical Board of California revised its influential guidelines for prescribing potentially addictive pain medications in 2014 while California officials have said recently that they are stepping up efforts to curb abuse of opioids. State public health officials recently received a $3.7 million Centers for Disease Control and Prevention (CDC) grant to improve prescription practices for opioids and President Barack Obama recently proposed adding $1 billion to the federal budget for treatment programs. Last month the U.S. House of Representatives passed a series of bills to combat opioid abuse, and the CDC released new guidelines in March of this year advising doctors against prescribing opioids to treat chronic pain. The effort to improve prescription practices for opioids also includes a July 1 deadline for California physicians licensed to prescribe or dispense them to sign up for CURES (Controlled Substance Utilization Review and Evaluation System) 2.0.

of this epidemic, and to provide

more understanding of the issues

and potential legal implications, we have consulted Steve Meister, former Los Angeles County Deputy District Attorney and principal of

Meister Law offices, a full-service

criminal defense firm, as well as local providers to offer expertise

and insight on the new guidelines from the CDC and California Med-

ical Board, precribing procedures and CURES 2.0. CDC GUIDELINES

tion, doctors in Los Angeles County and elsewhere

are finding themselves in the proverbial position of being between a rock and a hard place, as Peter

Richman, MD, LACMA’s president, and surely many other physicians see it. In his letter in the March issue

of Physician Magazine, Dr. Richman stated what’s

surely on the minds of a lot of physicians these days. “In the past, physicians were told that they were under-treating pain and could be liable under mal-

practice law for patient abuse,” Dr. Richman wrote. Today, many physicians worry that they may be held

criminally liable for prescription overdose and will therefore decrease their prescribing patterns.

Citing “an urgent response to the epidemic of overdose death,” the CDC in March issued new recommendations for prescribing opioid medications for chronic pain, excluding cancer, palliative and end-of-life care. The guidelines are directed mostly to primary care physicians, who prescribe nearly half of opiates. Among the 12 recommendations, the CDC listed three principles that are key to improving patient care: nonopioid therapy is preferred for chronic pain outside of active cancer, palliative and end-of-life care; when opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioids use disorder or overdose; and providers should always exercise caution when prescribing opioids and monitor all patients closely. Other recommendations include conducting a urine test before opioid therapy, starting at the lowest dose possible and avoiding doses of 90 morphine milligram equivalents (MME) or more, prescribing immediate-release as opposed to longer-acting opioids, and limiting treatment for acute pain to usually no more than seven days. And while some doctors applauded the government for telling doctors that opioids are not appropriate for long-term use, some pain specialists expressed concerns to the media that lawmakers, who lack experience in treating pain, will increasingly take steps to turn CDC’s guidelines into a rule. Medscape reported that the guidelines also charac-

terized the widespread abuse of opioids as a “doctordriven epidemic,” which prompted fierce opposition from healthcare professionals against what they perceived as an uninformed overreach of a government agency. Others feel that lawmakers are trying to put an unjust burden on physicians, who simply want to do right by their patients. Emil Avanes, MD, founder and director of Harmony Health MD in Glendale and LACMA’s District 2 president, said he sees the rampant abuse of opioids in the community and agrees with the CDC guidelines that opioids are powerful drugs that should be reserved for alleviating pain in cancer patients and those who are terminally ill. He said only in rare instances does he prescribe these powerful drugs to treat patients for other serious conditions, and then only for a very brief period of time. He feels that current measures do not sufficiently address the opioid epidemic and that the focus should be on comprehensive legislation. “Physicians are supposed to remove patients’ pain; we aren’t supposed to be the legal wing,” Dr. Avanes said. “If a patient says ‘I’m in pain’ and the physician judges that the patient isn’t in pain — that’s a judgment.” He believes that many patients who are addicted to opioids would benefit from treatment programs and seeing pain specialists. But even pain specialists say they are “feeling the

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C ONF RONT ING T H E C RIS IS | F EAT U RE

Physicians are on the front lines

In the midst of a national wave of opioid addic-

F EAT U RE | C ONF RONT ING T H E C RIS IS

pain” of the new guidelines. Robyn K. Sato, MD, who specializes in physical medicine and rehabilitation, pain and electrodiagnostics, told PNN that while it’s important to use serious pain medications with caution, she feels the pendulum has swung the other way now where people aren’t getting the care they need. She reported that her patients, including cancer patients, have trouble obtaining pain medications for legitimate pain syndromes. “The recent changes in regulations and climate of fear have had very serious consequences for this vulnerable population, including violations of their privacy, inability to obtain medication for their condition, poor treatment from pharmacists and public shaming of their condition,” she told PNN. Robert Bitonte, MD, JD, who specializes in physical medicine and rehabilitation and deals with chronic problems, told PNN that “physicians are still bound by practice guidelines and by law to be reasonable in all their behavior.” He added that to legislate what’s reasonable doesn’t take into account all the circumstances that are presented to physicians in every grade of severity. Steve Meister described the CDC guidelines as “numerous, quite vague and at odds with many state guidelines, including those in California,” which likely makes it even more challenging for doctors to know how to address the issue.

MEDICAL BOARD OF CALIFORNIA

While the CDC guidelines are not legally binding, those issued by the Medical Board of California for prescribing opioids are. “Law enforcement uses noncompliance with the

California guidelines as a theory of physician criminal liability and a basis for disciplinary action,” Meister explained. He noted that the Board’s guidelines were amended in November 2014, noting that the previous guidelines, released in 2007, didn’t address the opioid epidemic in a meaningful way. “At that time, the opioid epidemic wasn’t fully understood,” he said. What raises the burden for compliance even more, according to Meister, is that there are many competing sets of guidelines, even within the same state, issued by regulators, medical societies, insurance companies and others that can be at odds with each other, inconsistent or contradictory. “It means that you practically need a law degree to figure out how to practice tame medicine,” Meister said, adding, “As much instruction as physicians are getting in this area, none of it enables a physician or risk manager or a hospital administrator to know how to prescribe opioids in a medically appropriate or legally compliant manner.” “The Medical Board of California guidelines,” Meister said, “view everything a prescriber does through the lens of whether or not a prescription was written for a ‘legitimate medical purpose,’ which is a legal term whose meaning no one really knows and isn’t clearly defined by California law.” One way that a doctor can address this problem proactively, according to Meister, is by doing an audit, which his company, ScriptRight Healthcare Consultants, LLC, provides. The auditing process, Meister explains, can take one to three months and consists of a doctor filling out a compliance survey online, followed by a com-

Last month, an LA Times investigation based on confidential documents from OxyContin maker Purdue Pharma shed light on a major factor that may be contributing to why so many Americans are addicted to the painkiller. Contrary to Purdue’s claims that the opioid pain medication OxyContin lasts for 12 hours, the LA Times investigation found that it often wears off long before then and patients are experiencing serious withdrawal symptoms as it wears off. This, in turn, is leading doctors to prescribe stronger doses, which makes addiction – and overdose – a lot more likely.

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American Medical Association President Steven Stack, MD. recently addressed the issue and how physicians can immediately effect change in an impassioned open letter published in the Huffington Post. Dr. Stack speaks to physicians’ responsibility to address the epidemic. “The medical profession must play a lead role in reversing the opioid epidemic that, far too often, has started from a prescription pad.” “As a profession that places patient well-being as our highest priority, we must accept responsibility to re-examine prescribing practices,” he continues. “We must begin by preventing our patients from becoming addicted to opioids in the first place. We must work with federal and private health insurers to enable access to multi-disciplinary treatment programs for patients with pain and expand access for medication-assisted treatment for those with opioid use disorders. We must do these things with compassion and attention to the needs of our patients despite conflicting public policies that continue to assert unreasonable expectations for pain control.” He then details specific steps physicians can take to ensure best practices: “As a practicing emergency physician and AMA President, I call on all physicians to take the following steps - immediately - to reverse the nation’s opioid overdose and death epidemic: AVOID initiating opioids for new patients with chronic non-cancer pain unless the expected benefits are anticipated to outweigh the risks. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred. LIMIT the amount of opioids prescribed for post-operative care and acutely-injured patients. Physicians should prescribe the lowest effective dose for the shortest possible duration for pain severe enough to require opioids, being careful not to prescribe merely for the possible convenience of prescriber or patient. Physician professional judgment and discretion is important in this determination. REGISTER for and USE your state Prescription Drug Monitoring Program (PDMP) to assist in the care of patients when considering the use of any controlled substances. REDUCE stigma to enable effective and compassionate care. WORK compassionately to reduce opioid exposure in patients who are already on chronic opioid therapy when risks exceed benefits. IDENTIFY and ASSIST patients with opioid use disorder in obtaining evidence-based treatment. CO-PRESCRIBE naloxone to patients who are at risk for overdose.“ He ends with a plea for individual and collective efforts within the healthcare community. “As physicians, we are on the front lines of an opioid epidemic that is crippling communities across the country. We must accept and embrace our professional responsibility to treat our patients’ pain without worsening the current crisis. These are actions we must take as physicians individually and collectively to do our part to end this epidemic.” 1 6 P H Y S I C I A N M A G A Z I N E | J UN E 2016

prehensive audit at the doctor’s office involving interviews with the doctor and staff, chart reviews and inspection of the site. “We look beyond prescribing guidelines through all other intangible and unwritten factors that raise red flags for a cop that the medical board and law enforcement never reveal to doctors,” Meister said. There are too many red flags to list, he said. But he offered the following categories as potential risk factors where doctors can run into legal issues: physical location (medical building vs. retail shopping center), types of payment that a doctor accepts and doesn’t accept, where patients are referred from, the number of pills a doctor prescribes in a month, types of insurance accepted, whether a doctor gets paid predominantly in cash and whether he or she dispenses opioids in the office.

CURES 2.0

Effective July 1, physicians with an active medical license and a Drug Enforcement Agency certificate must be registered for access to CURES 2.0, the Controlled Substance Utilization Review and Evaluation System. CURES is the online state database that tracks the dispensing of controlled substances, seeking to prevent addicts from hopping from doctor to doctor to fill prescriptions. Meister advises doctors to take this deadline seriously. “If you don’t sign up on time, you are making it easy for law enforcement to come after you,” he said. On the upside, he noted, the new system marks a significant improvement from the old CURES system, which he described as virtually unusable. While not perfect, the new confidential database, used by physicians, pharmacists, law enforcement and epidemiologists to better track prescribing practices, has much better technology, is easier to use, is more accessible and current, he said. Besides signing up on time, Meister advises that doctors and their staff are properly trained to use the system. He also said it is not enough in the eyes of

pain, wrote Dr. Richman. He also advised doctors to take CME courses on narcotics topics and adopt guidelines to show good faith, immediately seek assistance when contacted by a state or federal agency, and consult with an expert to help develop best practices in the office and get recommendations to reduce risk. Finally, noting that Dr. Tseng discussed untreated depression in her final defense, Dr. Richman advised doctors who feel overwhelmed to get help themselves. “We need to develop wellness and diversion programs to maintain the health of the profession,” he wrote.

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the law to simply make a reference that a CURES run has been done. “I advise printing up a CURES run and putting it in the chart or making an electronic record,” he said. “An incomplete or insufficient use of CURES is to law enforcement just like shooting fish in a barrel when it comes to saying a doctor has broken the law.” Dr. Richman, in his PNN article, echoes the sentiments of many doctors who remain on heightened alert since the conviction of Los Angeles County physician Hsiu-Ying “Lisa” Tseng, DO. Dr. Tseng was convicted of three counts of second-degree murder in the deaths of three patients who died of narcotic overdose, 19 counts of unlawful controlled substance prescriptions and one count of obtaining a controlled substance by fraud. Performing a thorough history and physical examination, developing an assessment and describing a treatment plan are necessary components when it comes to properly managing patients with

In California, more than 4,500 people died from opioid overdoses in 2014, according to the latest data available from the CDC. The California Department of Public Health noted that in 2012, about 72% of opioid deaths among Californians involved prescription drugs.

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