spring 2016 â€˘ volume 8 â€˘ issue 1
Danesh Mazloomdoost, MD discusses
A Paradigm Shift in Pain From an effort to encourage compassionate care to the largest iatrogenic epidemic in history...
The United States is now the largest consumer of global opiates.
doc • Spring 2016
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doc • Spring 2016
Contents | Spring 2016
FROMTHEEDITOR Robert P. Granacher Jr., MD, MBA, Editor-in-Chief, Kentucky Doc Magazine
Post Operative Analgesia Following Abdominal and Urologic Endoscopic Surgery by Thomas K. Slabaugh, Jr., MD
Recent Federal Guideline And Marketing Changes In Opioid Prescription Policy by Robert P. Granacher, Jr., MD, MBA
PROFILE IN COMPASSION
Russell Eldridge and Compassionate Cancer Care by John A Patterson MD, MSPH, FAAFP
Opioids and the management of musculoskeletal conditions by Brent J. Morris, MD
The Elephant in the Room by Tuyen T. Tran, MD
Dying as Desired by Charles G. Ison, MD
FROM THE COVER
A Paradigm Shift in Pain by Danesh Mazloomdoost, MD
PHYSICIAN HEALTH & WELL-BEING
Ensuring Medical Staff Well-Being by John A Patterson MD, MSPH, FAAFP
Them’s fight’n words: Opioid abuse is now the largest iatrogenic epidemic in American history. Danesh Mazloomdoost MD, our featured LMS physician in this Spring Edition of KentuckyDoc magazine, has correctly guided us to a severe problem linked to the care of our patients with chronic pain. His article entices us with a panoply of evidence-based management techniques available now for chronic pain and he gives the promise of future scientific breakthroughs for non-opioid pain control. Moreover, we are shown the skill set of a highly trained board certified pain physician. Dr. Slabaugh, our current LMS president, provides a lucid introduction to the available techniques for acute pain control following endoscopic abdominal and urologic procedures. His article demonstrates options that may limit the need for prolonged opioid use while reducing the patient’s time in hospital. Brent Morris, MD, an orthopedic surgeon and expert in shoulder-elbow surgical treatment, guides us in the opioid management challenges in treating musculoskeletal conditions. Back to the opioid abuse problem. Dr. Granacher summarizes last month’s publication of the new CDC guidelines for prescribing opioids for chronic pain. He also outlines the FDA’s: A Proactive Response to Prescription Opioid Abuse. Part of FDA policy change due to opioid abuse is to address immediately the lack of non-opioid alternatives for chronic pain control. Leaving governmental policy issues aside, Tuyen Tran, MD asks us to look at “the elephant in the room.” Dr.Tran, an internist and addiction medicine specialist, contrasts the opioid abuse crisis with the myths against using medication assisted treatment for opioid addiction (MAT). In his customary fashion, John Patterson MD profiles the compassionate cancer care provide by local oncologist Russell Eldridge MD. John then introduces us to the strategies for ensuring physician well-being as practiced by Lexington Clinic CMO Robert Bratton MD. Last, but not least, among our physician writers is the poignant essay by Charles Ison, MD, “Dying as Desired.” Please read our Lifestyle Section article on traveling in Tokyo and our Business Section article by Jim Ray on how to grow your medical practice by branding yourself. Enjoy this issue and remember to care for yourself so you can care for your patients.
Robert P. Granacher Jr., MD, MBA Editor-in-Chief
Robert P. Granacher Jr., MD, MBA editor of Kentucky Doc Magazine Rice Leach, MD Tuyen Tran, MD Lowell Quenemoen, MD Amanda Faulkner, MD Tom Goodenow, MD John Patterson, MD
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Spring 2016 â€˘ Kentucky
Post Operative Analgesia Following Abdominal and Urologic Endoscopic Surgery By Thomas K. Slabaugh, Jr., MD Postoperative analgesia can be a challenge to both patients and surgeons. For patients, postoperative abdominal pain can limit mobility, inspiration effort and appetite potentially leading to DVT, deconditioning, atelectasis, pneumonia and dehydration. It is clear that pain can cause significant morbidity, and it is paramount that the surgeon has knowledge of multiple treatment modalities that can be used together to avoid comorbidity while optimizing patient comfort. Classically, opioid analgesia is a mainstay following abdominal surgery. Oral opiates are often used and can be supplemented with parenteral agents as needed if an inpatient setting is appropriate. Patient controlled analgesia, PCA, is utilized frequently as a way to avoid over use of parenteral opioid analgesia. With this approach the patient is able to control the dosing with computer driven limits to avoid over sedation and respiratory depression. In extreme cases, a basal rate of opiates can be administered with PCA in addition to the patient controlled bolus. This should only be used in cases where analgesia is difficult and the practitioner is familiar with basal rate administration. Unfortunately, opioid analgesia has its drawbacks, especially in abdominal surgery. First, respiratory depression must be guarded against. Reversal agents should be available especially in the case of PCA use. Respiratory depression can also lead to problems like atelectasis and pneumonia; thus, respiratory hygiene is imperative while patients are using parenteral opiates. Postoperative ileus is a second problem that can be linked directly to opiate use. Abdominal surgery, open or laparoscopic, can certainly cause ileus, but this ileus can be exacerbated by opiate use. Increased inhibitory neural input, heightened inflammatory responses, decreased propulsive movements and increased fluid absorption in the gastrointestinal tract hallmark opioidinduced bowel dysfunction. Treatment of this problem is typically supportive, limiting opiate use as tolerated. There are reversal agents, however, it is difficult to
induce reversal of the opioid-induced bowel dysfunction without reversal of the pain relief. Methyl naltrexone and alvimopan are recently developed opioid antagonists that are peripherally acting and have some success at reversal of opioid-induced bowel dysfunction. With avoidance of opioid induced comorbidity in mind, there are several approaches which have been successful in limiting amount of narcotic needed in the post operative setting. Examples include: use of antiinflammatory supplemental agents, use of continuous infusion analgesic pumps, use of epidural analgesia, and use of nerve blocks. Supplemental anti-inflammatory medication can significantly limit opiate analgesic requirement for the postoperative patient. Intravenous acetaminophen and ketorolac are both anti-inflammatory agents that are routinely used in treatment of postoperative pain associated with abdominal surgery. Both agents significantly limit the need for opiates thus preventing the potential opiate induced- comorbidities. Intravenous acetaminophen and ketorolac both need to be monitored for their toxicities, liver and renal failure respectively. Ketorolac is especially useful in the treatment of ureteral colic both in the postoperative setting and the setting of acute ureteral obstruction. In the case of ureteral obstruction, it not only serves as an anti-inflammatory but also limits ureteral peristalsis and spasm. Continuous infusion analgesic pumps are a popular method of treating incisional pain in laparoscopic and open abdominal procedures. These pumps continuously elaborate local anesthetic to the operative site via catheters that are left in situ for 36-72 hours. The pumps can be used in an inpatient and outpatient setting due to the ease of administration. Again, this strategy helps limit the need for narcotic analgesia thus improving outcomes by avoiding opioid-induced comorbid. Epidural analgesia is a unique, inpatient option for regional analgesia following abdominal surgery. This technique is typically selected for a patient who is expected to spend multiple days in the hospital, or expected to have a slow return of bowel function. Either local anesthetic or narcotic can be infused into the epidural space with good efficacy. Infection is unusual.
Limitations of epidural analgesia include: inability to anticoagulate, postoperative ileus, and bladder dysfunction resulting in prolonged urethral catheter use. Typically, the epidural infusion is managed by an anesthesia provider with experience in pain management. The transversus abdominis plane block, TAP block, was first described by Rafi in 2001. This technique is performed under ultrasound guidance perioperatively. An anesthetic block is administered into the plane superficial to the transversus abdominis muscle and deep to the internal oblique. This provides excellent postoperative analgesia for both laparoscopic and open abdominal procedures. As in the examples above, the key with the TAP block is avoidance of overuse of opiates which can result in significant morbidity. Postoperative pain management is essential in the field of surgery. While opiates are ubiquitous in this arena, multiple modalities are available to help avoid the potential associated comorbid problems. Many of these techniques not only limit opiate use but also decrease hospital stay. In turn these techniques can lead to better and more efficient outcomes as it relates to post operative recovery. About the Author Thomas K Slabaugh Jr., MD, is a urologist in Lexington Kentucky. He attended University of Kentucky medical school. He obtained his Â surgical and urologic training at Emory University in Atlanta Georgia.
doc • Spring 2016
Recent Federal Guideline And Marketing Changes In Opioid Prescription Policy By Robert P. Granacher, Jr., MD, MBA Larochelle et al. (2016) published research on 2,848 commercially insured patients, with ages between 18 and 64 years, who sustained a nonfatal opioid overdose during long-term opioid therapy for non-cancer pain between May 2000 and December 2012. Patients were followed over a median time interval of 299 days. Physicians re-dispensed opioids to 91% of patients after they had made a potentially fatal overdose. Two hundred and twelve patients had a second or third opioid overdose after being prescribed more opioids. After two years follow-up, the repeated overdose rate was 17% for patients receiving high doses of opioids after the index overdose. One just can’t make this stuff up. Unbelievably, almost all patients continued to obtain prescription opioids from their clinicians after they had made a potentially fatal overdose. This article further noted that research demonstrates that after an overdose, opioid discontinuation reduces risk for repeated overdoses. With regard to Kentucky, in 2013, there were 1,019 resident drug overdose deaths. This was a slight decrease from the prior high point in 2012. This placed Kentucky second among all states in our country for resident age-adjusted drug overdose death due to opioids (23.7/100,000). Of the more than 1,000 opioid overdose deaths, pharmaceutical opioids remained the primary cause of death, according to medical examiners. In 2013, pharmaceutical opioids were causally involved in 438 drug overdose deaths in Kentucky. Kentucky overdose deaths now exceed motor vehicle crashes as a cause of death from unnatural factors. In the 2011
to 2013 interval, the following Kentucky counties experienced the highest number of overdose deaths involving pharmaceutical opioids per 100,000 county residents: Bell, Clay, Floyd, Johnson, and Knox (Slavova et al. 2015). Within the last two months, two federal agencies have stepped up changes in guidelines for both treatment and marketing of opioids for chronic pain. In March 2016, the CDC published guidelines for prescribing opioids for chronic pain in the United States (C.D.C. 2016) These guidelines are CDC recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care. The following 12 guideline points are a summary of the entire CDC recommendations: 1. Non-pharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. 2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh the risk. 3. Before starting, and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy. 4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended release, long-acting opioids. 5. When opioids are started, clinicians should prescribe the lowest effective dose. 6. Long-term opioid use often begins with
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treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain, severe enough to require opioids. 7. Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. 8. Before starting, and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. 9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring programs (PDMPs) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. 10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications, as well as other controlled prescription drugs and illicit drugs. 11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. 12. Clinicians should offer or arranged evidenced-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patient with opioid use disorder.
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Kentucky is second among all states in our country for resident age-adjusted drug overdose death due to opioids. The Food and Drug Administration (FDA), in February 2016, published, A Proactive Response to Prescription Opioid Abuse (Califf et al. 2016). FDA policy is being revised immediately to respond to prescription opioid abuse by examining and promulgating regulations and guidelines for the following issues: 1. Balancing individual need and societal risk, 2. Meeting the need for timely action, 3. Reviewing labeling and post-marketing surveillance requirements, 4. Prioritizing abuse-deterrent formulations and overdose treatments, 5. Addressing the lack of non-opioid alternatives for pain management, 6. Creating clear guidelines for opioid use, 7. Managing pain in children, and 8. Developing a better evidence base.
It is hoped that Kentucky physicians will meet the challenge of modifying opioid prescription practices in Kentucky and increase their level of awareness by reviewing guidelines for opioid use and incorporating them into practice for the chronic pain patient. Moreover, medical schools, residencies and fellowship programs, should incorporate clear evidence-based curricula to teach the biological ramifications of acute versus chronic pain. All medical students, residents and fellows should be provided with up-to-date and evidence-based curricula to inform them of the contemporary management of chronic pain utilizing non-opioid treatments whenever possible. About the Author Robert P. Granacher, Jr., MD, MBA practices clinical and forensic neuropsychiaty in Lexington and Mt. Vernon, KY. He is a noted scientific author and past president of the Kentucky
Psychiatric Medical Association. He is currently president-elect of the Lexington Medical Society and Clinical Professor of Psychiatry at the University of Kentucky College of Medicine. References Califf, R.M., Woodcock, J., Ostroff, S. (2016). A proactive response to prescription opioid abuse. N.Eng. J. Med. Epub ahead of print February 4, 2016. DOI: 10.1056/NEJMsr1601307 C.D.C. (2016). CDC guideline for prescribing opioids for chronic pain: United States, 2016. MMWR 65; 1-37. Larochelle, M.R., Liebschutz, J.M., Zhang, F., et al, (2016). Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study. Ann. Int. Med. 264: 1-9. Slavova, S., Bunn, T.L., Gao, W. (2015). Drug overdose deaths in Kentucky, 2013. Lexington, KY: Kentucky Injury Prevention and Research Center.
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Profile in Compassion
Russell Eldridge and Compassionate Cancer Care By John A Patterson MD, MSPH, FAAFP I first became aware of the quality of Russell Eldridge’s doctor-patient relationship as my own patients and their families told me about their experiences under his care. I was particularly appreciative of the compassionate care provided to patients for whom there were no further treatment options. When asked how he has matured as a compassionate physician, he says “I have no real secret – I’ve had to put it together as I go” although he credits growing up working in his father’s drug store as an early career influence. He saw the rewarding relationships between his pharmacist father and their small town neighbors. He considered engineering as a career due to his love for science and math but his interest in people led him to choose the pre-med track in college. He graduated with a BA in psychology and also did graduate work in psychometric assessment- combining his love of science, math and people. During medical school, he knew he wanted “to be somebody’s doctor” and considered family practice or general internal medicine. He was drawn to oncology for its close relationships with patients as well as the scientific aspects of pharmacologic therapies. He says “I feel fortunate to have good health and supportive relationships at home. I think it’s important to have other professionals to talk with. Ideally they are in your workplace, but if not then outside the office. I find I can talk to them in a way I can’t to anyone else. That brings up the topic of permission to admit your feelings and discuss that part of cases just like we discuss the medical and scientific aspects of patient care. I don’t think some of us ever learned that.” He and his oncology Russell Eldridge
Spring 2016 • Kentucky
“I feel fortunate to have good health and supportive relationships at home. I think it’s important to have other professionals to talk with. Ideally they are in your workplace, but if not then outside the office.” – Russell Eldridge
you disabled? partners remind each other of the need to set limits and regularly take time off. His partners are all hard workers and have good working relationships that include this important aspect of peer protection, self-care and well-being. He believes health care organizations should spend more time encouraging such collegial relationships. Elvis Donaldson has been an oncology partner of Eldridge’s for many years and says ‘he truly listens to his patients and is empathic to their needs. His practical, down-to-earth manner makes people feel comfortable. I can’t imagine anybody feeling uncomfortable in conversation with Russ. Even when there is no more treatment available, he explains ‘we will support you and see that you have the highest quality of life possible.’” Lorraine Le Stephens
is Eldridge’s office nurse and describes him as ‘kind-hearted’. She adds, “He makes sure he introduces himself to each person in the room- not just the patient. As an oncologist, he knows he is not only taking care of the patient but working with their family member/care provider to care for the patient as a team. Dr. Eldridge always sits down at the patient’s level to talk. He allows the patient to ask questions or discuss concerns, and after taking care of the patient’s needs, he always asks if the family member/care provider has any questions.” He reminds the family caregivers that taking good care of their loved ones includes taking good care of themselves. He reminds them “You don’t have a cape on your back and a big red ‘S’ on your shirt. You are not Superman or Superwoman.”
Andrew Merrill is supervisor of counseling for Hospice of the Bluegrass, where Eldridge provides end-of-life and palliative care in-service for staff. He describes Eldridge’s approach as bridging the gap between aggressive care to prolong life versus supportive and compassionate care. Kim Wilder is administrative director for orthopedics at Baptist Health Lexington, where she has worked as an RN for many years. She says “I love him. He is wonderful with nurses as well as patients.” She recalls being apprehensive 18 years ago having to call and wake Dr. Eldridge at 5 AM about a dangerously low platelet count on an ICU patient on ventilator support. She remembers him saying – “I just want to thank you for calling me about this patient.” This was such an unexpected and welcome response Continued on Next Page...
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He allows the patient to ask questions or discuss concerns, and after taking care of the patient’s needs, he always asks if the family member/care provider has any questions.
from a doctor, she jokingly recalls wanting to ask, ‘”Are you sure you have an MD after your name?” Regarding the ways in which he sustains compassion in his life, he says “Home has to be a good place. It’s hard to remain compassionate if home life is a struggle.” He feels fortunate to have found a part of medicine that “fits me”. He explains, “Oncology has scientific and clinical questions that intrigue and stimulate me. At the same time, I’m most comfortable in clinical areas where I get to know the patient as a person. To help learn about the patient as a person, I often ask, “Where did you grow up? Where do you live? What do you do? Who/what matters to you?“ Regarding our responsibility to train and educate medical students and residents to properly balance self-care and patient care, he recalls receiving only a 1 hour lecture on self-care and stress during medical school and nothing in residency. “I think it needs to start early and be a continuous process. I think the first step is to say out loud to all the students that “Yes, it does matter” while we are also teaching them the science and clinical skills they have to master to be a good physician. They need to hear us say ‘If you don’t take care of yourself, you cannot be a good doctor.’ I think talking about it and giving them permission to talk about it is a big step in the right direction. We need to show them how NOT to do it, to hopefully avoid those sad stories we occasionally see with burnout, inappropriate responses and behavior, and avoid the isolation many of them end up feeling. It is often assumed they will learn/figure out some of this on their own during the ‘apprenticeship’ of post-grad years, but it needs to be formally addressed in residency programs- especially those in primary care and medical specialties that involve close and long-term relationships.” Thankfully, those medical students and residents, as well as our professional colleagues and patients, have physicians like Russell Eldridge to guide, mentor and nurture compassion in the practice of medicine. About the Author John A Patterson MD, MSPH, FAAFP chairs the Lexington Medical Society’s Physician Wellness Commission, is past president of the Kentucky Academy of Family Physicians and is board certified in family medicine and integrative holistic medicine. He is on the family practice faculty at the University of Kentucky College of Medicine, Saybrook University’s School of Integrative Medicine and Health Sciences (San Francisco) and the Center for Mind Body Medicine (Washington, DC). After 30 years in private family practice in Irvine KY, he now operates the Mind Body Studio in Lexington, where he offers integrative medicine consultations specializing in mindfulness-based approaches to stress-related chronic conditions and burnout prevention for helping professionals. He can be reached through his website at www.mindbodystudio.org
doc • Spring 2016
Opioids and the management Proud to of musculoskeletal conditions Partner with You By Brent J. Morris, MD, Shoulder & Elbow Surgeon, Lexington Clinic Orthopedics Sports Medicine Center, The Shoulder Center of Kentucky
United States. The United States comprises less than 5% of the world’s population yet consumes nearly all of the world’s prescription opioid supply (80% of the global opioid supply, including 99% of the global hydrocodone supply).1 Patient-reported pain in the outpatient setting has remained relatively unchanged over the last decade, yet there have been significant increases in opioid prescriptions for pain.2 The increase in opioid prescriptions for pain has not been met with similar increases in nonopioid alternatives such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.2 The proliferation of opioid prescribing has led to many unanticipated consequences. Diversion of opioids for nontherapeutic use has led to significant increases in opioid addiction and unintentional overdose deaths.
Five Star Senior Living Musculoskeletal conditions represent a significant portion of patient visits to priReferral Guide mary care providers in the United States. Management of acute and chronic musculoskeletal conditions can be challenging for both primary care providers and for specialty providers. Opioid medications are used more commonly to treat musculoskeletal conditions, including osteoarthritis. The expansion of indications for opioids has led to a significant increase in opioid prescribing in the
Opioid-related deaths are now more common that heroin, cocaine, suicide, and motor vehicle related deaths.3 The unfortunate impact of nontherapeutic opioid use is evident; however, the negative impact of therapeutic opioid use for the treatment of musculoskeletal conditions is now being recognized as well. Preoperative opioid use for patients with knee osteoarthritis has been associated with significantly worse outcome scores, increased postoperative complications, and prolonged recovery following total knee arthroplasty.4 Preoperative opioid use prior to spine surgery has been associated with worse postoperative outcomes, increased length of stay, increased intraoperative and postoperative opioid demand, and decreased opioid independence one year after surgery.5-7 Similar results have been noted following total shoulder arthroplasty and reverse
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Spring 2016 • Kentucky
shoulder arthroplasty in patients with a history of preoperative opioid use for shoulder arthritis. Preoperative opioid was associated with significantly worse preoperative and postoperative shoulder function scores relative to patients without a history of preoperative opioid use.8,9 Patients with preoperative opioid use can respond very well to shoulder replacement surgery, but it has been shown that they do not reach the same level of improvement compared to nonopioid patients. Furthermore, patients without preoperative opioid use have been shown to have significantly better postoperative patient satisfaction after total shoulder arthroplasty compared to patients with preoperative opioid use.8 The American Academy of Orthopaedic Surgeons (AAOS) recently issued a position statement in response to the rise in opioid prescribing to help guide physicians that manage musculoskeletal conditions.10 The AAOS recognized the need for physicians to manage musculoskeletal pain, while understanding the direct and indirect contributions to the opioid burden in the United States. The AAOS called for a culture change among physicians, patients, and caregivers regarding opioid prescribing and pain control in musculoskeletal conditions. Proposals included standardized opioid prescribing protocols, limits on the duration and amount of opioid pills prescribed, and avoiding the use of extended-release opioids. The AAOS recommended avoiding opioids for the routine management of pre-surgical pain, nonoperative, or chronic musculoskeletal conditions. Objective risk assessment tools were suggested to help better identify patients at risk for greater opioid use as well as opioid use tracking. Improved care coordination and physician collaboration was recommended. Orthopaedic surgeons and other musculoskeletal specialists can help to better communicate and collaborate with primary care physicians and other specialties regarding the treatment of musculoskeletal conditions. The negative consequences of nontherapeutic opioid use are apparent. The detrimental effects of therapeutic opioid use, especially in the management of musculoskeletal conditions, are now more clearly identified. Additional work is needed to better understand and treat pain associated with musculoskeletal conditions. The association between therapeutic opioid use and worse patient outcomes has been highlighted. Additional efforts are needed to explore the complexities of pain and outcomes in the management of these common conditions. About the Author Brent J. Morris, MD is an orthopedic surgeon and fellowship-trained shoulder and elbow specialist at Lexington Clinic Orthopedics Sports Medicine Center and the Shoulder Center of Kentucky. Dr. Morris received his medical degree from the University of Kentucky College of Medicine and completed an orthopedic surgery residency at Vanderbilt University. He completed a shoulder and elbow fellowship at Texas Orthopedic Hospital in affiliation with the University of Texas Health Science Center at Houston. Dr. Morris has presented research nationally and internationally and has published extensively on various orthopedic topics including the impact of opioids on orthopedic patients. Resources 1. Manchikanti L, Singh A: Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 2008;11(2 suppl):S63-S88. 2. Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care 2013;51(10):870-878. 3. Manchikanti L, Helm S II, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician 2012;15(3 suppl):ES9-ES38.
4. Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am 2011;93(21):1988-1993. 5. Lee D, Armaghani S, Archer KR, Bible J, Shau D, Kay H, Zhang C, McGirt MJ, Devin C. Preoperative opioid use as a predictor of adverse postoperative self-reported outcomes in patients undergoing spine surgery. J Bone Joint Surg Am 2014;96(11):e89. 6. Armaghani SJ, Lee DS, Bible JE, Shau DN, Kay H, Zhang C, McGirt MJ, Devin CJ. Increased preoperative narcotic use and its association with postoperative complications and length of hospital stay in patients undergoing spine surgery. Clin Spine Surg. 2016 Mar;29(2):E93-8. 7. Armaghani SJ, Lee DS, Bible JE, Archer KR, Shau DN, Kay H, Zhang C, McGirt MJ, Devin CJ. Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. Spine (Phila Pa 1976). 2014 Dec 1;39(25):E1524-30. 8. Morris BJ, Sciascia AD, Jacobs CA, Edwards TB. Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25:619-623. 9. Morris BJ, Laughlin MS, Elkousy HA, Gartsman GM, Edwards TB. Preoperative opioid use and outcomes after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(1):11-16. 10. American Academy of Orthopaedic Surgeons Information Statement: Opioid use, misuse, and abuse in orthopaedic practice. http://www.aaos.org/positionstatements/statement1045/ Accessed March 22, 2016.
Quit You’ve thought about it for years. You know you need to do it. And there’s no time like the present. But you aren’t quite sure how to quit smoking. Your doctor is here to help. Visit us online to learn what questions to ask your doctor, access all available resources, and stick to the plan so you can hit pause on smoking.
doc • Spring 2016
The Elephant in the Room By Tuyen T. Tran, MD Opioid addiction is an unfortunate epidemic which has recently surpassed motor vehicle related injuries as the 4th leading cause of death in the United States. In 2014, CDC reported that 18,893 deaths were related to overdose of opioid medications. And, sadly, Kentucky is the most afflicted state. (Graph 1 displays the rate of death from overdoses of prescription opioids in the United States more than quadrupled between 1999 and 2010.) These alarming trends triggered the Department of Health and Human Services (HHS) to deem prescription-opioid overdose deaths an epidemic and prompted
multiple federal, state, and local actions. The objectives included 1) providing prescribers with the knowledge to improve their prescribing decisions and the ability to identify patients’ problems related to opioid abuse, 2) reducing inappropriate access to opioids, 3) increasing access to effective overdose treatment, and 4) providing substance-abuse treatment to persons addicted to opioids. Unfortunately, the most crucial objective, providing treatment to persons already addicted to opioids, was not emphasized! Opioid abuse and dependency causes a significant social, economic, and biomedical toll. Opioid substitution therapy has been proven to reduce illicit opioid use, lower
rates of arrest and recidivism, decrease rates of disease transmission, and increase treatment compliance for co-occurring morbidities. The gold standard for the treatment of opioid addiction is Medication Assisted Treatment (MAT). In 2014, SAMHSA (Substance Abuse and Mental Health Services Administration) sponsored the investigation of evidence based practices (16 adequately designed Randomized Control Trials and 7 meta-analyses) specifically looking at the effectiveness of Buprenorphine. The conclusion was, “BMT [Buprenorphine Medication Assisted Treatment] is associated with improved outcomes [greater than 80% depending upon dosage and duration of treatment] compared with placebo for individuals and pregnant women with opioid use disorders.”1 The authors added, “BMT should be considered for inclusion as a covered benefit.”1 Additionally, the National Safety Council warned, while “…detoxification seems to be the most attractive [it does not involve the ongoing use of medications], in fact, this method is the least effective and may be the most dangerous [risk of overdose is extremely high].” In 2011, NIH conducted a world-wide review, specifically examining the evidence for Buprenorphine misuse. The authors concluded, “Wherever there is access to any Opioid Sales, Admissions for OpioidAbuse Treatment, and Deaths Due to Opioid Overdose in the United States, 1999-2010.
Data are from the National Vital Statistics System of the Centers for Disease Control and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental Health Services Administration, and the Automation of Reports and Consolidated Orders System of the Drug Enforcement Administration.
Spring 2016 • Kentucky medication with abuse potential, diversion is likely to follow, making it unsurprising that buprenorphine diversion has been documented.”2 They stressed that despite the documented diversion, Buprenorphine products were clinically effective and safe for the treatment of opioid dependence. Buprenorphine’s safety profile, ceiling effect at high doses, and its ability to be co-formulated with naloxone to limit injection abuse and lower abuse potential compared to full opioid agonists make it a suitable medication for office-based treatment of opioid dependency. The authors recommended, “Strong consideration should also be given to the medical, social, public health, and economic benefits that arise when opioid-dependent individuals use buprenorphine in a therapeutic manner to self-treat addiction and withdrawal symptoms or as a harm reduction approach to manage the risks associated with drug dependence.”2 The key driver of the overdose epidemic is the underlying substance-use disorder (SUD). SUD is a chronic disease and similar to other chronic diseases (i.e., diabetes, hypertension), SUD is generally refractory to cure; but, effective treatment and functional recovery are possible. As the evidence-based medicine studies demonstrated, medicationassisted therapies (MAT) are available; but, these modalities are underutilized! Of the 2.5 million Americans 12 years of age or older
who abused or were dependent on opioids in 2012 (according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration [SAMHSA]), fewer than 1 million received MAT. A study of heroinoverdose deaths in Baltimore between 1995 and 2009 found an association between the increasing availability of methadone and buprenorphine and an approximately 50% decrease in the number of fatal overdoses.3 There are many barriers which contribute to low access and utilization of MAT. The most significant one is the misconception that MATs merely replace one addiction with another. The second barrier is the bias toward an abstinence model. As Jason Cherkis, Huffington Post author of “Dying to be free” questioned, if we have evidence-based medicine that demonstrated effectiveness of MAT, why are we not practicing it? And another barrier is policy and regulatory mandates which limit MAT in regards to dosages prescribed, annual or lifetime medication limits, and pre-authorization to reimburse for MAT. The epidemic of prescription-opioid overdose is complex. Access to MAT is crucial for patients. It is also necessary to implement strategies to curb inappropriate prescribing of opioids. However, do not ignore the elephant in the room, treatment of already addicted patients!
About the Author Tuyen Tran, MD emigrated from South Vietnam after the war. He completed his undergraduate in biology/chemistry and medical school at the University of Missouri – Kansas City in a six year program. His is currently boarded in internal medicine and addiction medicine. References 1. Cindy Parks Thomas, Catherine Anne Fullerton, Meelee Kim, Leslie Montejano, D. Russell Lyman, Richard H. Dougherty, Allen S. Daniels, Sushmita Shoma Ghose, and Miriam E. Delphin-Rittmon. Medication-Assisted Treatment with Buprenorphine: Assessing the Evidence. Psychiatric Services 2014 65:2, 158-170 2. Yokell MA1, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/ naloxone diversion, misuse, and illicit use: an international review. Curr Drug Abuse Rev. 2011 Mar;4(1):28-41. 3. Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health 2013;103:917-922
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Know the Ten Signs Rice C. Leach, M.D. named 2016 Public Health Hero On Monday, March 14, Dr. Rice C. Leach, MD received the 2016 Public Health Hero Award in honor of his “lifetime of service to medicine and public health, for making the community healthier, for making the Lexington-Fayette County Health Department stronger and for helping Lexington be well.” On Thursday, March 17, Mayor Jim Gray presented Dr. Leach with a city proclamation declaring that day Rice C. Leach Day in the city of Lexington.
Rice C. Leach, M.D. receives Jack Trevey Community Service Award The Jack Trevey Community Service Award recognizes a member of the Lexington Medical Society who performs outstanding service to the community by direct involvement in the community beyond his/her role as a physician. This year’s recipient was Rice C. Leach, M.D., LMS President, Thomas K. Slabaugh, Jr., M.D. presented Dr. Leach with the Jack Trevey Award on Thursday, March 17. Many LMS members were on hand to help Dr. Slabaugh thank & honor Dr. Leach on his many years of service to Medical Society and the community.
If you or someone you know is experiencing memory loss or behavioral changes, it’s time to learn the facts. Early detection of Alzheimer’s disease gives you a chance to begin drug therapy, enroll in clinical studies and plan for the future. This interactive workshop features video clips of people with Alzheimer’s disease. The program will be held on Thursday, May 5th from 7-8pm at the Lexington Public Library, Beaumont Branch located at 3080 Fieldstone Way. Registration required. Call the Alzheimer’s Association at 800272-3900.
Healthy Habits for Your Brain and Body For centuries, we’ve known that the health of the brain and the body are connected. But now, science is able to provide insights into how to optimize our physical and cognitive health as we age. Join us to learn about research in the areas of diet and nutrition, exercise, cognitive activity and social engagement, and use hands-on tools to help you incorporate these recommendations into a plan for healthy aging. The program will take place on May 24, 2016 from 10:00am-11:00am at the Woodford County Extension Office, 184 Beasley Road, Versailles KY. 40383. To register for this program, please call the Alzheimer’s Association 24/7 Helpline at 1-800-272-3900.
Understanding and Responding to Dementia-Related Behavior Behavior is a powerful form of communication and is one of the primary ways for people with dementia to communicate their needs and feelings as the ability to use language is lost. However, some behaviors can present real challenges for caregivers to manage. Join us to learn how to decode behavioral messages, identify common behavior triggers, and learn strategies to help intervene with some of the most common behavioral challenges of Alzheimer’s disease. The program will take place at the Beaumont Public Library, 3080 Fieldstone Way, Lexington, KY 40513 on April 27th, 2016, from 1-2:30 p.m. Registration is required; please call 1-800-272-3900.
Spring 2016 • Kentucky
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Lexington Medical Society Essay Contest 2015: Active Physician
Dying as Desired By Charles G. Ison, MD
“The day of my birth, my death began its walk. It is walking toward me, without hurrying.” – Jean Cocteau, “Postambule” We are all going to die. If one wants to bet on a sure thing, bet on that cold fact. As medical professionals, we all secretly believe that we are helping our patients’ battle death. We see ourselves as our patients’ indispensable allies in fighting a war that, to
It’s Friday Night…
be blunt, they will ultimately lose. Healthcare professionals must decide, along with the patient and his family, when care switches from curative to end-of-life care. We also need to decide what constitutes a desired quality of life at its end. All three parties, and society in general, must decide on how to reconcile these two decisions with how much they will cost and who will ultimately pay for them. There comes a time—especially for those with chronic, progressive health conditions—where nothing can be done from a medical perspective to cure a patient or improve her health. We may know at which point that occurs in a given disease process, but this does not mean that the patient or her family are ready to accept this. The matter can be explained as tactfully as possible, but they may feel like they are surrendering if they agree. Some may be
blessed with an abundance of hope. They may be people of strong faith who are expecting a miracle to change everything. We are human: there is absolutely nothing wrong with believing these things. These people often become more accepting of initiating end-of-life care as their conditions deteriorate, but some may not. Some patients and family members are pessimists—or “realists” as they may claim—who may be ready to give up on care too soon. They should be tactfully persuaded not to stop looking for a cure for their condition. Attitude is important, but it is not the only factor involved in dying. Otherwise quite a few people would be immortal. At a minimum, the healthcare providers and the patient should decide together when it is time for end-of-life care. One hopes that the family would respect the patient’s wishes in this case. If the patient is
Save the Dates
April 15 April 15
April 16 April 16
Two Great Events, One Great Speaker Register at: Lexingtondoctors.org
Social, Food, & CME “ 5 Things Early-Career Physicians Need to Know about Leadership” What: Enjoy an informal evening of relaxing and socializing with your peers in the beautiful atmosphere of the Signature Club. Heavy appetizers and cash bar culminating with a engaging leadership seminar geared toward early career physicians. W h o: Early-Career Physicians, Residents & UKCOM Medical Students W h e n : April 15, 6:30p.m. to 9:00p.m. W h e r e : The Signature Club, 3256 Lansdown Drive, Lexington, KY 40502
Costs: No charge for LMS members Approved for 1.5 hours AMA PRA Category 1 Credits
Breakfast, Fosteringsnacks, Teamwork: How Physicians & & Managers CME Create High-Performance, Close Knit, “ FNo-Drama o s t e r i n g Healthcare T e a m w o r kTeams :
How Physicians & Managers Create High-Performing, Close Knit, No-Drama Healthcare Teams” What: Highly interactive leadership workshop for physicians and their practice managers. Who: All LMS Members W h e n : April 16, 8:00a.m. to 12:30p.m. W h e r e : Lexington Center(near Rupp Arena), Thoroughbred Room 1 430 West Vine Street, Lexington, KY 40507
Costs: No charge for LMS members & their Practice managers. Non LMS physician: $150, Non LMS physician practice manager, $75 Approved for 3.75 hours AMA PRA Category 1 Credits
Speaker: Joe Mull, M.Ed., We are bringing Joe back for a third tme due to raving reviews by our members. Joe is the former head of Learning & Development for Physician Services at the University of Pitsburgh Medical Center.
Spring 2016 • Kentucky
incapacitated, the family’s opinions become a lot more important. Of course, a patient may have made his decision about when to initiate end-of-life care and what kind should be given in this event. He may have also assigned power-of-attorney to a relative or trusted friend. Once end-of-life care is initiated, the patient, the medical professionals, and the family should decide on what will constitute good quality of life for the patient. Since it is the end of the patient’s life, her desires should be given priority. It is up to the healthcare providers and the family to help facilitate this expected quality of life for the patient. Most people would want to be able to do what they wanted to do, see who they wanted to see, and remain lucid and as pain-free as possible at the end of their lives. These are all laudable goals that can serve as optimizations or ideals. Medical professionals must balance the patient’s desires with what is realistic from a healthcare standpoint for them to actually do. Since at this point all are hopefully in agreement that the patient is dying, somewhat different rules can be applied. If the patient wants to try riding a horse, let him. If a patient decides that he wants to banter with his brother without falling asleep, help him decrease his pain medications safely. Assisted suicide is now legal in some countries and some states. There are patients and there are healthcare providers that would have no qualms in making this a part of end-of-life care. Others may find it disturbing or even morally abhorrent. At this time it is a very controversial part of care. If the patient or a medical professional disagrees with this, then a new therapeutic alliance with a different healthcare provider may be necessary. Family members may have been very protective and even somewhat authoritarian toward the patient before she entered end-of-life care. This type of role-reversal may be the hardest on them. They must also give her wishes priority—within reason, of course. They should treasure the time they have left with the patient as best they can. In our society, dying costs money. Quite a lot of it is spent in a patient’s final days in the intensive care unit, or on that last trip to the emergency department. Those who know that they are at the end of their lives often have the luxury of deciding where they get to die. If the patient desires it, he can die at home surrounded by family. This is less costly than weeks on a ventilator. If a patient desires it, though, emergency care can be sought. That adds to the cost of dying and ties up resources, but it is what the patient perceives as quality of life at that time. Hopefully healthcare providers—and family members—have very carefully gone over directives for end-of-life care in multiple scenarios with the patient. As mentioned
Healthcare professionals must decide, along with the patient and his family, when care switches from curative to end-of-life care. above, living wills and power-of-attorney designation can help ensure that a patient’s last wishes are carried out as she sees fit. This also saves money and resources by not providing care that the patient does not desire. If a patient at the end of her life wants everything done for her should she become obtunded, then it is the responsibility of the medical professionals to help her understand the ramifications of this. If she does not change her mind, so be it. Both healthcare providers and family members can sound very callous when mentioning the cost of healthcare around or concerning a dying patient. The natural inclination for both parties is to want as much healthcare as possible for someone who is critically ill, even if he is dying. If no advanced directives have been given, then it becomes the responsibility of the patient’s family to communicate what they think his desires for end-of-life healthcare were. The medical professionals can help the family, once again, to understand the ramifications of these decisions for the patient. In this case, if the family wants more instead of less healthcare, then not knowing or having the patient’s delegated desires, the family’s desires should be followed. Cost should only enter into the conversation if the healthcare providers are asked by the family about it. In the end, someone is going to have to pay for end-of-life care. The patient will not need to worry, since he will be dead. His estate will have to pay what any insurance — Medicare or otherwise—does not. Anything that is not paid by the patient or by insurance carriers will either be paid by state programs or swallowed by the
medical professionals and healthcare facilities involved in her end-of-life care. These costs are passed along to society as a whole through increased taxes, decreased services, and increased healthcare charges. The end of life is just as important a part of life as any other portion of it. In our society, for a variety of reasons—including, ironically, better healthcare—dying may be by far the most expensive part of our lives. People want to die with dignity. They want the quality of the last part of their lives to be just as good as all the parts that came before. Deciding beforehand where and how they want to spend the end of their lives, along with the input of medical providers and family members, can go a long way in making sure this happens. Many such patients would choose to die at home surrounded by loved ones in hospice care rather than in an intensive care unit. This not only saves society money and resources, it also increases the quality of life for patients by allowing them to choose their end-of-life care as they desire it. It is grim to associate dying with a winwin scenario, but perhaps in this case it is strangely appropriate. About the Author Charles G. Ison, MD is a native of Lexington. He graduated from the University of Kentucky College of Medicine and did his residency in Pediatrics at the University of Florida. Currently he is practices at Pediatric & Adolescent Associates in Lexington.
doc â€˘ Spring 2016
From the Cover
A Paradigm Shift in Pain By Danesh Mazloomdoost, MD Not long ago, even palliative care patients struggled for pain relief, prompting the World Health Organization among many other organizations to focus on pain care access. What started in the late 1980s as an effort to encourage compassionate care for terminal conditions evolved into the largest iatrogenic epidemic in history; the US is now the largest consumer of global opiates. While less than 5% of the global population, we utilize 80% of the global opiate supply and 99% of the available hydrocodone1. In fact, hydrocodone is the most prescribed medication in America at 131 million scripts, beating out the next most prescribed medication, by over 37 million scripts2. In spite of this dramatic reliance on opiates, quality of life or functional
indicators do not reflect improvement in health. Rather, opiate initiation more often correlates with future disability and worsening conditions3. Many factors have contributed to the evolution of the opiate epidemic. Most efforts to address this multifaceted epidemic are narrowly focused on issues such as abuse deterrence, compliance monitoring or egregious pill-mills. But the problem rages on and metastasizes to other concerns like the growth in heroin. Introspection into our field poses risks of triggering defensiveness and denial. Nonetheless, solutions start with accountability and it involves challenging longbelieved myths about pain management.
acute injury or palliative care. The focus of these efforts hinged on liberal access to opiates â€“ an excellent solution for some of these problems, but short-sighted for others. Pain became a dump-bucket diagnosis which no longer differentiated situations and conditions for which opiates are not the ubiquitous solution and may even cause harm. The zeal of these efforts shifted patient focus from the nuances of coping and valuable therapeutic workup to an entitlement of a painfree existence no matter what. Pain was made into the Fifth Vital Sign and a metric for reimbursement. No other field is held to a zero-tolerance standard, nor is it fair to promote the illusion of its possibility to patients.
Regulatory & patient advocacy groups
Starting in the late 1980s, wide-scale advocacy platforms focused on pain, identifying many undertreated scenarios like
Sedentary lifestyles and poor nutrition have made the populace vulnerable to obesity and degenerative pathologies that culminate in pain. The mantra of opiate initia-
Spring 2016 • Kentucky
tion and titration to effect fails to address the underlying etiology of pain while marginalizing the motivation for change and rehabilitation. Once a patient bypasses the acute phase of opiate exposure, the physical dependency creates an impression that the pain is worse without opiates when in fact, the pain of withdrawl exaggerates the underlying cause of pain. After the pharmacologic duration of action, opiates have a rebound effect and thus magnify the pain experience when the medication has worn off. Once re-medicated, relief from the rebound pain gives the perception that only opiates can stave off pain. Patients remain in a vicious cycle with the notion that anything less than unrestricted opiate escalation is cruel.
Payor models often have unintended consequences. In pain management, there are numerous examples that hinder effective care and promote strategies without proof of efficacy. Insurance reimbursement has long focused on compliance monitoring, radiologic diagnoses (often superseding skilled physical exam findings), urine toxicology, and invasive options including surgery and joint replacement. Low health literacy obstacles regarding pain often require more time with patients, a service that is not proportionately reimbursed. It is far easier and more lucrative to operate or write a script than to dissect the problem and educate the patient. As a result
patients may opt for options that are less effective and more costly to healthcare. Services often lacking in the repertoire of payers involve psychological, lifestyle counselling, rehabilitation, or regenerative options, all tools which have very strong track records of cost-efficacy.
In the short span of 20 years, opiates have become the most prescribed medication in the country, a boon to many pharmaceutical companies. Similar to strategies used by the tobacco industry, the risks and benefits of opiates were misrepresented. As a field, we trusted without verifying and many extrapolated claims trumped solid science in pain
“Solutions start with accountability and it involves challenging long-believed myths about pain management.” – Dr. Mazloomdoost
Continued on Next Page...
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management. The conversation was often shifted to monitoring for egregious addiction or lesser adverse effects rather than the lacking efficacy or problems of physical dependency and rebound pain. Once chronically exposed, many patients cannot return to abstinence, even upon resolution of the original complaint. Thus the decision to initiate opiates and the reasonable doses prescribed are enormous life-altering choices, often sidelined by the imperative to treat regardless of a condition’s long-term response to opiates. Nationally, lawsuits have been filed against pharmaceuticals as a result of misleading claims but as clinicians we must learn from our own mistakes to vet the knowledge we gain from our pharmaceutical counterparts.
Pill mills have long been a scapegoat for the opiate epidemic. While undoubtedly unscrupulous businessmen and clinicians profited from the epidemic, the vast majority of opiates originate from wellintentioned physicians. Physicians engaged in opiate prescribing often embrace the acute improvements they hear from patients and these gains often overshadow the diminishing efficacy over the ensuing visits. In blurring the lines between opiate prescribing and true pain management, healthcare undermines the complexity of proper diagnoses and long-term planning
for chronic pain conditions. Articles and CME programs can never relay the density of subspecialty training, but until recent regulations, many physicians conveyed the notion of expertise without the proper training to back it. Granted the field is new and the need is tremendous but how many nephrologists dabble in cardiology, or psychiatrists attempt a hysterectomy? Pain is not one condition for which there is a single categorical cure in opiates. Pain is the symptom of many conditions, some of which may benefit from an opiate, but many of which magnify in the context of chronic opiates. Managing pain sustainably is possible. A well-versed pain specialist will identify the origin of pain and help the patient understand the rehabilitative options available. If the condition cannot be restored to functional status, then the objective becomes interrupting the pain pathway prior to its perception in the brain. For this there are many novel options. Furthermore, non-surgical regenerative techniques which leverage mesenchymal stem cells and growth
factors are rapidly evolving to offer more options than previously available for many painful conditions. The future of pain management offers a vast array of innovative options, but healthcare must embrace a paradigm shift from symptom management with opiates to disease management by specialists who understand the many nuances of pain. About the Author Danesh Mazloomdoost MD, a born and raised Kentuckian, pursued his medical degree and anesthesiology training from Johns Hopkins and subsequently a fellowship in pain management at MD Anderson Cancer Institute. He is the Medical Director of Pain Management Medicine, a multi-disciplinary practice begun by his family of physicians in the 1990s. Dr. Danesh advocates for a paradigm shift in healthcare to reduce its reliance on opiates. He guides patients through rehabilitative and regenerative techniques in healing the underlying causes of pain using translational science and the latest innovations in the field.
1. https://www.asipp.org/documents/ASIPPFactSheet101111.pdf 2. http://www.webmd.com/news/20110420/the-10-most-prescribed-drugs 3. Franklin, G. M., et al. (2008). “Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort.” Spine (Phila Pa 1976) 33(2): 199-204.
Spring 2016 • Kentucky
2016 Lexington Medical Society
Essay Contest PRIZES AWARDED
1st place prize $600 2nd place prize $300 3rd place prize $100
Active Physician Resident Medical Student
“Healthy and happy doctors provide better care, define barriers and solutions to physician wellness.”
Prizes awarded for first, second and third place in each of the three categories
Due no later than August 15, 2016.
visit lexingtondoctors.org for details
doc • Spring 2016
Physician Health and Well-Being
Ensuring Medical Staff Well-Being By John A Patterson MD, MSPH, FAAFP In his role as Chief Medical Officer for Lexington Clinic, Robert Bratton MD is concerned about medical staff well-being in light of the growing awareness of our national epidemic of physician stress, burnout and suicide. He says, “I have seen many of my colleagues battle this in various ways. Two years ago, we lost one of our physicians to suicide. Most of us never suspected this desperate act by a colleague who was obviously struggling. Stress and burnout have a profound effect on your ability to cope and can affect your care of your patients. Studies have shown - if physicians are burned out - they are less likely to provide high quality care and their patient satisfaction scores are typically not as high. Really I don’t think that is any surprise to us as physicians.”
“Studies have shown - if physicians are burned out - they are less likely to provide high quality care and their patient satisfaction scores are typically not as high.” – Robert Bratton MD
He has observed some generational differences between physicians in a couple of important ways. Physicians under age 50 seem less stressed by the demands of technology whereas older physicians often cite technology as a main source of their practice-related stress. Early career physicians also seem more aware of the value of team-based, interdisciplinary care models, work-life balance and self care, whereas older physicians are more likely to have a ‘captain of the ship’ mentality, habitually leading and dominating rather than co-leading and collaborating. They are also less likely to prioritize self-care activities. He says, “Physicians are faced with everincreasing demands on their personal and professional lives and especially primary care physicians who are often left with the vast amount of paperwork and care coordination responsibilities that are now necessary to care for patients. Estimates suggest that at least 400 physicians commit suicide every year. That is
equivalent to 3-4 medical school classes per year taking their own life. Furthermore, some studies show that many physicians now discourage others (including their own children) from going into medicine. With these facts in mind, I feel it is important to recognize physician burnout and develop ways to enhance work-life balance, self-care and mindfulness so that we can help our physicians avoid burnout and hopefully renew their joy in caring for patients.” With these concerns in mind, the Lexington Clinic Employee Assistance Program offers 3 free counseling visits for staff and physicians with an outside behavioral health provider with the option for complete anonymity. Impaired or disruptive physicians and those with substance abuse disorders can be referred to the Program for Distressed Physicians at Vanderbilt’s Center for Professional Health in Nashville. Physician members of the Lexington Medical Society also have access to LMS’s Physician Wellness Program, providing 6 free, completely anonymous counseling visits annually. “We are talking more and more about these lifestyle issues and trying to educate our physicians regarding signs of burnout, depression, and stress and ways to address them. Recently our Board of Directors has been proactive in discussing the issue and we reached out to the Lexington Medical Society for guidance. As a result, we will soon offer our medical staff a formal presentation on managing stress and preventing burnout using mindfulness approaches.” He feels personally fortunate to have never been overly burdened by stress. He feels protected in part by the inherent maturational factors of established physicians and has gained confidence in his role as a physician leader. He exercises 4-6 days a week, currently focusing on spinning at a downtown club. He enjoys hunting, fishing and golf and spending time with friends. His best friends are mostly nonphysicians, which helps him keep a broader perspective on life. He feels fortunate and knows such a good social support system is part of the answer to managing physician stress and the loss of satisfaction with medicine as a career. He says, “I think all of us are looking for new ways to adjust and cope with the ever-changing demands in medicine. Many docs are exploring alternatives to traditional medical practice models. Some are working in concierge practices. Some are working with pharmaceutical
Spring 2016 • Kentucky
companies or insurance companies and others may be pursuing leadership roles in larger organizations. I have watched others become withdrawn and seemingly lose their compassion and caring attitude. Their personalities seem to change and they become negative and bitter. Some struggle with their relations at home and others struggle with depression and substance abuse. Some, it seems, manage to find the positive and adapt to the changing environment without missing a step. I think those are the ones with a healthy outlook on the current situation and a good support system around them. They are optimists and seem to ‘look at the glass half full’. Many have a good sense of humor to get them through difficult times. Those who are well-adjusted and have a good support system seem to adjust and cope better with the changes that are taking place in medicine.” Regarding our responsibility to train and educate residents and medical students and properly prepare them for careers in medicine,
he believes medical schools should incorporate more self-care skill development into the formal curriculum. “I think some of the work restrictions in residency (although controversial) may help residents set limits on what physicians can do and can’t do while keeping the patient’s safety and best interest in mind. I think we should start earlier in our careers with developing coping mechanisms to deal with stress.” Since most of today’s physicians are products of a system that did not offer them such training, organizations like Lexington Clinic and the Lexington Medical Society are taking seriously their responsibility to help preserve the compassionate service ethic that leads most of us to choose medicine as a career. There is every reason to believe that resourceful physicians and physician organizations will find skillful and effective ways to take good care of ourselves, our colleagues, our families, our patients and our communities.
About the Author John A Patterson MD, MSPH, FAAFP chairs the Lexington Medical Society’s Physician Wellness Commission, is past president of the Kentucky Academy of Family Physicians and is board certified in family medicine and integrative holistic medicine. He is on the family practice faculty at the University of Kentucky College of Medicine, Saybrook University’s School of Integrative Medicine and Health Sciences (San Francisco) and the Center for Mind Body Medicine (Washington, DC). After 30 years in private family practice in Irvine KY, he now operates the Mind Body Studio in Lexington, where he offers integrative medicine consultations specializing in mindfulness-based approaches to stress-related chronic conditions and burnout prevention for helping professionals. He can be reached through his website at www.mindbodystudio.org
doc â€˘ Spring 2016 â€˘ Lifestyle Section
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Lifestyle Section • Spring 2016 • Kentucky
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When is the last time you took time off to have a fun vacation with the love of your life, just the two of you? For many couples, the answer is usually before kids came along. Well, sharing a vacation adventure with your partner is a very effective and fun way to spice up your romance and/or rekindle your relationship. Exploring an unfamiliar destination together is a great way to work on communicating and being patient with one another! With this in mind, we work with couples (and families) to design adventure-filled journeys to interesting destinations that both challenge and reward them. Tokyo, Japan is one such great destination. If you have not been, imagine leaving daily life behind for a while and exploring exotic Tokyo with your loved one. If you have already been, imagine returning to share new experiences on a memorable journey! So, if you are wondering about what you can do in Tokyo, here’s a fun itinerary (one of our couples just embarked on) to inspire your imagination. Naturally,
we work with each of our couples to create itineraries tailored to their personal taste and desires. You dream it, we’ll plan it and make it happens!
7-Night Tokyo Itinerary DAY 1
• Arrive in Tokyo, Japan (Haneda Tokyo Airport) • Private transfer by car or limousine (30 minute ride) to Hilton Tokyo • Check into Hilton Tokyo (Deluxe King Room or Suite) • Keep in touch with loved ones back home via wired or wireless internet access, stay entertained with cable TV and an MP3 deck, or simply curl up on the comfortable easy chair and enjoy the stunning city views. Treat yourself to a delicious meal at the 24/7 Marble Lounge or enjoy drinks at St. George’s Bar, while relaxing to the tunes of live music. DAY 2
• Relax and sightsee in Tokyo. Visit beautiful and tranquil Shinjuku Gyoen National Garden, historic Senso-Ji temple, etc. DAY 3
• Train to scenic Hakone-machi, Japan • Check into Hakone Yunohana Prince Hotel • a Japanese-style hot spring inn and hotel in the pristine Hakone area, an ideal location in which to gaze up at the starry sky and to enjoy the sight of the changing seasons to the fullest. Enjoy your meal in the Sagami Dining Area as you
look out onto the vivid garden ( Japanese-style table and chair seating). • 2-Day Mount Fuji Adventure, Hakone with Bullet Train • Escape the big-city bustle to explore Mt Fuji ( Japan’s highest mountain). With an informative guide, you’ll visit 5th Station (7,546 feet above sea level), cruise Lake Ashi and take a ride on the Mt Komagatake Ropeway. Then soothe away your cares in an ‘onsen’ (hot spring bath) at your hotel. DAY 4
• Explore exquisite Hakone-machi resort town at your leisure, using a transportation pass. • Bullet train back to Tokyo DAY 5
• Hilton Tokyo - relax and sightsee in Tokyo – more excursions, explore restaurants, theaters, etc. DAY 6
• Day trip to Yamanashi Prefecture including wine and fruit tasting • Enjoy this day trip from Tokyo and explore a 600-year-old temple, enjoy picking strawberries, tasting local wines, enjoying the views of cherry blossom, as well as Kawaguchi lake, and much more. • Return to Tokyo by tour bus DAY 7
• Hilton Tokyo - relax, shop, and/or sightsee in Tokyo DAY 8
• Check out of Hilton Tokyo • Private transfer by car or limousine to Haneda Tokyo Airport • Depart for home
doc • Spring 2016 • Business Section
Grow Your Practice by Thinking of Yourself as a Brand By Jim Ray For years, the given way a physician grew a practice was through referrals from colleagues and associations with certain hospitals and/ or insurance plans. The environment is changing. While these traditional channels remain important, the consumer is more empowered to seek out information about a specific physician. That shift is impacting how physician groups and individual practioners grow their respective practices. Today’s consumer is much more inclined to read online reviews, visit websites and even online physician directories. The need to establish and monitor information has become increasingly more important to a successful practice. Rather than referring a patient to a colleague from medical school, physicians may be encouraged (even pressured) to refer that patient to another member of the hospital network. Overtime, this may erode the traditional flow of new patients to your practice.
I encourage professionals to begin thinking of themselves as brands. This may alter your perspective on how accessible you are to the general public.
Let’s consider a few of the implications. Brands such as GE, Apple, Starbucks and even Littmann (the company which may have made the stethoscope you use) all focus on producing great products. More importantly, these brands seek to instill a distinct image in your mind about the product and/or service offered. It’s about the “experience.” The same applies to you and your practice. That’s why you’ve invested so heavily in your education and training. You’re providing a service and you want your patients and their families to be happy with the care they receive. Ultimately, you hope they were sat-
isfied enough to recommend you to friends and family. This is simple brand positioning. Consider how many times your patients are given the opportunity to complete surveys about their experience. While we want to know that the care provided was effective and met expectations, there’s another reason we ask those questions. We want to know if there was a problem that needs to be addressed and/or resolved. This fact alone provides insight into an interesting fact. When it comes to effective branding, it’s the market, not the company (e.g. physician), that determines the brand’s value. While we may have logos and color schemes those aren’t your brand. They’re merely representations of it. Your brand is based on the value attributed to it by the patients and families who interact with you.
Many of us are aware that a happy patient may tell a few people. On the other hand, a dissatisfied patient will tell everybody. The Internet has become a repository for information about anything and everything. It includes tools consumers can use to tell others about their experiences through ratings and online reviews. If you haven’t taken time in the last few months to research how the market is reporting about you, it may be time for you to do a dive deep. A few negative reviews can have a significant impact on your practice. If you have an office manager, discuss setting up a periodic review of various online properties to monitor comments. Here’s a quick list of online rating and review sites that appeared on the first page of Google when I searched for my own internist: • Google Business Listing – Encourages consumers to Write a Review • Healthgrades.com – Reports Patient Satisfaction Ratings • Vitals.com – Asks if you’ve visited a specific physician and prompts you to Share
Your Experience • RateMDs.com – Provides patient ratings on Staff, Punctuality, Helpfulness and Knowledge • Healthcare.com – Provides opportunity to Write a Testimonial and Rate this Provider • WebMD.com – Asks you to Rate This Doctor When you think of yourself as a brand, your much more focused on the market, the value it attributes to you and how it positions you vis-à-vis your colleagues. Today’s consumers know they have access to information and they’re not afraid to use it. This fact provides an interesting opportunity for you. If you’re in private practice, have a concierge practice, or may be thinking about transitioning back into a private practice, here are a few simple marketing tips to consider: First, how easily can people find information about you and your practice? While online directories are one component, you should give some thought to a professionally developed website. The advantage is that you control the content. A website provides you and your staff with the means to influence the market and attract new patients. More importantly, you may be able to outrank those ubiquitous online directories. This enables you begin influencing your brand’s perception. While some prospective patients are interested in your CV, many more will be interested in learning about what they should expect from you. Remember, it’s about the experience. A professionally developed website can convey the messages and images you intended. Second, how current is the information about you, your location & contact information? There are tools that can be used to standardize this information across various online properties. Interestingly, when that simple data (Name, Address and Phone) are consistent across the Internet, your website is usually rewarded with higher search rankings. This is especially important for new practices or physicians who have moved to different locations and/or groups.
Business Section • Spring 2016 • Kentucky
Third, consider adding social media as a way for you and/or your staff to better connect with existing and prospective patients. A well-designed and maintained Facebook page and result in massive exposure for your practice. Social media is a terrific tool for providing helpful information about your office, general information about conditions and/or treatments, new services or procedures, etc. Used effectively, it can reinforce your position as the subject matter expert. I’m not recommending you try to become pop-medicine’s next Dr. Oz or Dr. Phil. Consider, however, why major brands implement social media campaigns. They can have a positive impact on the bottom line. Fourth, explore the option of starting a blog. Blogging is an extremely effective way to provide information about your specialty. If done properly, blog posts can appear in Google search results, just like websites, directories and other sources of information. A blog enables you to demonstrate your expertise. For example, you might begin providing updates and answers to common patient questions. An office manager can easily upload a “Question of the Week” to your blog. That information can be disseminated to your social media properties and featured prominently on your website. The
time needed to do this is surprisingly brief. The impact, however, can be significant. Finally, for those of you who like to push the envelope, implement a video component to your marketing campaign. The power of video is astonishing. The information in a video allows people to feel connected to you in ways plain text simply can’t match. Surprisingly, video content can show up in Google search results, can be included in blog posts and uploaded to your social media channels. Here are some interesting facts about video: • Videos will soon be 90% of all Internet traffic (Robert Kyncl, YouTube VP) • Videos show up in 65% of the Google search results (Search Metrics) • Videos have a 41% higher click-through rate vs. plain text (Econsultancy) • 60% of visitors will watch a video before reading site text (Diode Digital) • Cisco predicts online video to become 75% of all mobile data traffic by 2019 • The retention rate for video can reach 65% vs. 10% for text-based information (Social Media Today) Over the years, I’ve written many industry articles and provided seminars designed to help professionals with business develop-
ment issues. I’ve spoken on a local, regional and national basis to audiences in highlycompetitive environments. There are business fundamentals that some have been able to ignore up until now. The market is evolving and how professionals chose to adapt will determine their success rate. Thinking of yourself as a brand is a key step in developing a strategy to increase your exposure to new and prospective patients. It also puts into place processes that will help to protect and influence your reputation. About the Author Jim Ray earned a BA in Business and his MBA. He managed two multi-million dollar businesses before transitioning into Internet consulting. He later launched his regional consulting practice to help professionals operate more effectively and more profitably. Jim presents an ongoing seminar series and contributes business development articles to a variety of professional publications. He has been invited to speak at national meetings for Internet marketing and has lead several, national webinars on various marketing topics. For more information, visit www.JimRayConsultingServices.com or connect with him on Linkedin.
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Take Care of Your Patients by Taking Care of Yourself
The Lexington Medical Society
Physician Wellness Program
TAKE CARE OF YOUR PATIENTS BY TAKING CARE OF YOURSELF The Physician Wellness Program (PWP) was designed as a safe harbor for physicians to address normal life difficulties in a confidential and professional environment.
WHY WAS THIS PROGRAM CREATED? Being a physician isn’t easy. Difficulties with the current health care delivery system, maintaining a healthy work/ life/family balance, and dealing with the normal stresses of everyday life can take their toll on physicians. We serve not only as treating physicians, but many times as counselors to our patients who turn to us for guidance. Who do we turn to when we need to talk through an issue or get some coaching for how to handle stress in our life? Too often the answer is “no one,” and that is regrettable because it is imperative that we be as healthy as possible in our role as health care providers. We deserve to function at our best in all areas of our life. By addressing areas of difficulty, we can decrease our stress levels and increase our levels of resilience.
Some examples of those difficulties include: •
Depression & anxiety
How PWP Works We have contracted our program with The Woodland Group. The Woodland Group will provide counseling to active physician members of the Lexington Medical Society, up to six visits in a calendar year. Non-emergency sessions will be scheduled during regular business hours. Emergency sessions can be scheduled on a 24-hour, 7 days-a-week basis. Seven licensed psychologists make up the Woodland Group and have been vetted by LMS. Steven Smith, Ph.D. and Sandra Hough, Ph.D. are our program coordinators and will serve as points of contact to access PWP. The Woodland Group will maintain a confidential file for each physician, but no insurance will be billed and LMS will not be given any information about those who utilize the program. As such, this program is completely confidential which is crucial to its success. LMS will pay The Woodland Group a monthly bill based on the number of sessions provided. The Woodland Group will verify LMS membership from the physician finder on the LMS webpage.
TO MAKE YOUR APPOINTMENT 1) Call the confidential hotline at 1-800-350-6438 and leave a message in either Dr. Smith’s or Dr. Hough’s voice mailbox. 2) They will call you back to schedule an appointment. It’s that simple!
PWP Benefits 6 free sessions each calendar year Complete confidentiality Easy access Convenient location (535 W. 2nd Street, Suite 207) 24/7 availability
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