2018 ANNUAL SCIENTIFIC SESSION Saturday Handouts€¦ · 2018 ANNUAL SCIENTIFIC SESSION Saturday...

2018 ANNUAL SCIENTIFIC SESSION Saturday Handouts

February 23-24, 2018 • Grandover Resort • Greensboro, NCThis continuing medical education activity is sponsored by the American College of Physicians

1

MSK examination skills

ACP North Carolina Chapter

Claudia L Campos, MD, FACP

[email protected]

1

2

In one word could you describe how you feel?

• Text CLAUDIACAMPO786 to 22333

3

2

4

lower backshoulder

knee

5

Systematic approach to patients with MSK complaints

6

3

Lower Back Pain Facts

70% of acute LBP are due to muscle strain or sprain

Most resolve after 2 weeks

> 6 months of sick leave 50% return to work

10% develop chronic lower back pain

Peak between ages 35 and 55

Acute back pain less than 4 weeks, subacute 4 to 12 weeks, and chronic more than 12 weeks

7

Lower Back Pain Facts

Estimated to affect 8 out of 10 Americans at some point in their lives

Main reason for missed days at work

Second most common reason for doctor's visits

Estimated 75% to 90% of patients back pain disappears spontaneously within four to six weeks

8

Non spinal causes of back pain

Back/buttocks/leg pain

Hip OAPiriformis syndromeIschial bursitisSacroiliac joint dysfunction/sacroiliitisRadiculitis/ radiculopathyMyofascial pain

Common innervation

https:/Wikipedia9

4

The 3 minute Lower back Physical Exam

10

Spinous process tenderness?

Red flags associated with the highest post‐test probability of a vertebral fracture:

Older age

Prolonged use of corticosteroids

Severe trauma

Presence of contusion or abrasion

Downie A et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347:f7095

11

Hip Osteoarthritis: pain patterns

Groin

Buttock‐back

Anterior thigh

Posterior thigh

Anterior knee

Shin and calf

Khan NQ et al .Hip osteoarthritis: where is the pain?

Ann R Coll Surg Engl 2004;86:119–21.

12

5

Piriformis Syndrome

Special tests

Pain with palpation of the sciatic notchFAIR: Flexion Adduction Internal Rotation

Piriformis sign

• By Patrick J. Lynch & KDS4444 ‐https://commons.wikimedia.org/wiki/File:Skeleton_whole_body_ant_lat_views.svg, CC BY‐SA 2.5, https://commons.wikimedia.org/w/index.php?curid=53169641

13

Sacroiliac joint pain

14

Rotator cuff evaluation

15

6

16

17

Clinical features

Aching pain in the top of the shoulder, lateral aspect of the upper arm, and deltoid insertion

Pain with movement particularly abduction and internal rotation

Night pain when rolling onto the affected side

Restriction of shoulder movements and weaknesslifting, or reaching behind

18

7

Shoulder Anatomy: anterior view

http://www.investinlibya.org/analyzing‐anatomy‐of‐the‐shoulder‐and‐arm/19

Shoulder Anatomy: posterior view

http://www.investinlibya.org/analyzing‐anatomy‐of‐the‐shoulder‐and‐arm/20

Rotator cuff pathology

21

8

22

Among pain provocation tests, a positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9‐7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23‐0.54]).

Hermans J et al. SMA: Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review. JAMA. 2013, 310: 837‐847. 10.1001/jama.2013.276187.

23

Practice time: painful arc test

24

9

Testing for Rotator cuff tear

Drop arm test External rotation lag test

Sensitivity (%) 10–73 46–98

Specificity(%) 77–98 72–98

LR and Confidence Interval CI

3.3; 95% [CI], 1.0 to 11 7.2; 95% [CI], 1.7 to 31

25

Practice time: External Rotation Lag Test

26

27

10

Meniscus tears

28

Meniscus tears

• More common in men than in women 2.5:1 to 4:1.• Most common activities: cutting or pivoting (iesoccer, basketball, wrestling, football, gymnastics, and skiing)

• Medial meniscal tears are more common than lateral meniscal tears

• Incidence peaks in men in the third decade• In women, incidence remains constant beginning in the second decade

• <30 years: single traumatic event• >30 years:degenerative tears become more common

29

Meniscus: special tests

Smith BE, Thacker D, Crewesmith A, et al. Special tests for assessing meniscal tears within the knee: a systematic review and meta‐analysisBMJ Evidence‐Based Medicine 2015;20:88‐97 30

11

A ‘mechanical’ block to a full range of movement or a ‘mechanically’ unstable knee would usually indicate an MRI and a surgical opinion.

31

Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five

year follow-up

32

Surgery vs PT for a Meniscal Tear andOsteoarthritis

WOMAC 20.9 vs. 18.5

Katz et al N Engl J Med. 2013 May 2; 368(18): 1675–1684

33

12

Do you want to practice the Thesallytest?

34

Thank you!

[email protected]

35

references

• Hermans J et al. Does This Patient With Shoulder Pain Have Rotator Cuff Disease? The Rational Clinical Examination Systematic Review. JAMA. 2013;310(8):837‐847. doi:10.1001/jama.2013.276187.

• Hegedus EJ Shoulder examination ; Systematic review. Br J Sports Med 2008;42:80‐92 doi:10.1136/bjsm.2007

• Johnson MAJ, et al Acute Knee Effusions: A Systematic Approach to Diagnosis. Am FamPhysician. 2000 Apr 15;61(8):2391‐2400.

• Katz et al. Surgery vs PT for a Meniscal Tear and Osteoarthritis. N Engl J Med. 2013 May 2; 368(18): 1675–1684

• Herrlin et al. Is arthroscopic surgery beneficial in treating non‐traumatic, degenerative medial meniscal tears? A five year follow‐up. Knee Surg Sports Traumatol Arthrosc (2013) 21:358–364

• McHale K.J. et al. Physical examination of meniscus tears. The meniscus. Springer. 2010

• Smith BE, et al. Special tests for assessing meniscal tears within the knee: a systematic review and meta‐analysis. BMJ Evidence‐Based Medicine 2015;20:88‐97.

36

13

Injection supplies for large joints

• Medications: 1 cc triamcinolone 40 mg/cc2cc lidocaine 1 or 2 %

• Syringes: 3 cc for injections10 cc for arthrocenthesis

• Needles: 25 Gauge 1.5 Inch for injections20 Gauge 1.5 Inch for injections

• Clean with betadine or chlorprep• Bandaid• Gloves

37

1

SYSTEMATIC APPROACH TO EKG

1

Systematic Approach to ECGAdopt a systematic approach to ECG assessment

• Rate• Rhythm• Axis• P wave and PR interval• QRS• ST segment• T wave• QT interval• Additional waves

Bundle of His

http://www.yorkheart.com/Patient‐Heart‐Education/how‐your‐heart‐works.aspx2

3

2

4

5

6

3

7

8

9

4

10

11

12

5

13

14

15

6

16

17

18

7

19

20

21

8

22

23

24

9

25

26

27

10

28

29

30

11

31

1

CODE BLUE/ Management of Common Unstable Scenarios Encountered during Residency

PJ Miller, MD

Wake Forest Baptist Medical Center

Who we are:

PJ Miller, MD

Combined Internal Medicine/Pediatrics

Hematology

Critical Care Medicine

2

Crystal M. Anderson, RN, BSN, CEN, SANE


Conflicts of Interest

• I have no conflicts of interest to report

3

2


Goals and Objectives (Yours)

• To better understand common pitfalls of running a code and how to avoid them

• To learn styles of effective communication

• To learn how to establish control for effective teamwork

• To have fun

• To have a group discussion where we all teach and all can learn

4


Goals and Objectives (Mine)• To lead and engage a discussion on “how” to run a code

• To offer skills and insight that you can incorporate into your own style

• NOT to read overly detailed slides that you’ll forget

• To use humor and poorly timed jokes as a learning process

• To have fun

5

Overview of BLS and ACLSCrystal Anderson, BSN, RN, CEN, SANE

3


You found a dead guy… Now what?

• Call for HELP!!• You cannot code someone alone…

• Begin chest compressions until help arrives

• 100‐120 compressions per min• At least 2” deep (2‐2.4” with feedback device)• 30:2 ratio of compressions to ventilations

Unless there is an advanced airway…

Continuous compressions 1 breath every 6 seconds

7


The cavalry has arrived…

1. Give Oxygen

2. Attach the monitor/defibrillator

3. Identify the rhythm…

8


Wait… who are the cavalry?

Ideally you will have…• Airway

• Compressor

• Monitor/Defibrillator

• Medications

• Timer/Recorder

• Team Leader

9

4


Shockable Rhythms

10

Wake Forest Baptist Medical Center 11

SHOCK!!CPR for 2 min

IV/IO Access

Pulse/Rhythm check

SHOCK!!

CPR for 2 min

Epinephrine 1mg every 3‐5 min

Pulse/Rhythm check

SHOCK!!

CPR for 2 min

Amiodarone 300mg IVP

Pulse/Rhythm check

SHOCK!!

CPR for 2 min


Pulse/Rhythm check

SHOCK!!

CPR for 2 min

Amiodarone 150 mg IVP

Pulse/Rhythm check


Non‐Shockable Rhythms

12

This isn’t TV…

5


CPR for 2 min

IV/IO Access

Pulse/Rhythm check

CPR for 2 min


Pulse/Rhythm check

Pulse/Rhythm check

CPR for 2 min

H’s & T’s

CPR for 2 min


Pulse/Rhythm check

CPR for 2 min

H’s & T’s


WHY DID THIS HAPPEN!?!

H’s T’s

Hypovolemia Tension Pneumothorax

Hypoxia Tamponade (Cardiac)

Hydrogen Ion’s (Acidosis) Toxins

Hypo‐ / Hyperkalemia Thrombosis (Pulmonary)

Hypothermia Thrombosis (Coronary)

Hypoglycemia Trauma

14


THEY HAVE A PULSE!!!

15

Place an airway if not already

done

Maintain Oxygen

Saturation & Capnography

Maintain Blood Pressure

Get an EKG

STEMI

CATH LAB!

ICU

Not a STEMI

ICU

AIRWAY

BREATHING

CIRCULATION

6


Post Cardiac Arrest Care…

The fun isn’t over yet…

Now you have to keep them alive!

16


http://cpr.heart.org/AHAECC/CPRAndECC/General/UCM_477263_Cardiac‐Arrest‐Statistics.jsp


Now let’s do this a bit differently…

Top 10 people you DO NOT want to be while running a code…

18

7


Mr. Freeze

ComicBook. “Arnold Schwarzenegger's Mr. Freeze Costume Almost Killed Him.” DC, ComicBook.com, 5 Sept. 2017, comicbook.com/dc/2017/06/20/arnold‐schwarzeneggers‐mr‐freeze‐costume‐almost‐killed‐him/.

19


Super Saiyan (high energy)

dbz‐dokkanbattle.wikia.com/wiki/Stunning_Metamorphosis_Super_Saiyan_3_Goku.

20


Out of control guy/girl

“Pyramids Harlem Shake ‐ Egypt ‐ .YouTube, YouTube, 22 Feb. 2013, www.youtube.com/watch?v=9DSrW_eJJy4 ”.هرم شيك

21

8


The Multi‐tasker

“The Multi‐Tasker.” Thrive With ADD, 5 Feb. 2012, thrivewithadd.com/multi_tasker_lg/.

22


The Know‐It‐All

www.faithfellowshipministries.net/new‐blog/2014/7/21/dont‐be‐a‐know‐it‐all.

23


The Houdini

www.oliverbmagic.com/2017/06/22/makes‐magic‐popular/.

24

9


The Accessorizer

i.pinimg.com/736x/bc/2d/1e/bc2d1e7b25f24521025c4f0346aaf8bb‐‐cool‐stuff‐off‐road‐jeep.jpg.

25


The Bicarb Guy

Cain depicted after killing his brother by Henri Vidal, Tuileries Garden, Paris

en.wikipedia.org/wiki/Facepalm.

26


The Mime

www.gettyimages.com/detail/photo/mime‐shrugging‐high‐res‐stock‐photography/523428206.

27

10


The Never Gonna Give You Up

28


Debriefing

“Debriefing following a simulation event is a conversational period for reflection and feedback aimed at sustaining or improving future performance.”

Palaganas, J., Fey, M., Simon, R. Structured debriefing in simulation‐based education. Advanced Critical Care. 2016;27:78–85.

29


“Deep learning can be achieved during debriefing and often depends on the facilitation skills of the debriefer…”


30

11


“…poorly facilitated debriefings may create adverse learning, generate bad feelings, and may lead to a degradation of clinical performance, self‐reflection…”


31


Debriefing – 3 Main Phases

• Reactions Phase

• Understanding Phase

• Summary Phase


32


Unique Scenarios

33

1

Leading Together: Views From The American College Of Physicians

Darilyn V. Moyer, MD, FACP

EVP/CEO American College of Physicians

1

Many Thanks!

• To all on the frontlines of care who do the heavy lift of patient care

• To all members, staff and leadership at the ACP

2

Disclosures

• I am a full time staff member of the American College of Physicians

• I have no financial interests to disclose

3

2

Educational Objectives

• Review trends in healthcare financing and costs, industry consolidation, and advocacy initiatives

• Review provocative trends in the democratization of healthcare including telehealth, healthcare teams, and “the patient will see you now,” phenomena

• Review the challenges of the GME funding and physician pipeline

4

An All Too Familiar Patient…

A 40 year old patient with type 2 DM on insulin presents to the clinic (substitute ED) for the 4th

time in 3 months with a blood sugar ~400. VS are stable, PE shows no signs of dehydration, trace ketones and 4+ glucose in UA, BMP nlexcept for BS 425.

What do you think could be going on?

5

6

3

Expand access and coverageImprove public healthSupport research and scienceOppose discriminationReduce health care disparitiesSupport primary care workforce

Lower excessive Rx pricesReform and improve paymentsImprove quality measuresReform medical liability systemMake EHRs work for doctorsReduce crushing administrative burden

ACP’s “Big Tent” advocacy agenda addresses a wide range of issuesaffecting internists and their patients . . .

And whatever else pops up!

7

Some background about ACP’s perspective

• Largest medical specialty society in the world: 148,000 members

• Represents the diversity of internal medicine

– Ambulatory generalists, hospitalists, subspecialists

– Academics, practitioners, educators, researchers, administrators

– From solo practice to large groups

– Medical students, residents, fellows, practicing clinicians, retired physicians

– Domestic and international membership

• Welcomes non‐physician affiliate members

8

ACP’s focus at a glance

• The science of medicine

– Annals of Internal Medicine

• The clinical practice of medicine

– Clinical standards, guidelines

• The education and professional development of physicians

– MKSAP, meetings and courses

• The ‘quadruple aim’ of healthcare

– Better care, better health, physician professional satisfaction, lower per capita costs

• The future of medicine

– Students, residents, fellows

• Professional satisfaction

– Payment reform, practice redesign

9

4

10

11

• Two areas of greatest expenditures and mostrapid growth: imaging and tests

Tests

Imaging

12

5

13

14

15

6

16

17

18

7

19

Physician Employment Dynamics

20

21

8

The $15 Billion Dollar GME Pyramid

22

23

24

9

2016 ACP/AAIM GME Financing Positions

• Maintain societal commitment• All payer• Try to get at true costs• Selectively lift caps• Infuse transparency• Combine DME/IME• Examine potential Performance Measures• Ignite innovation• Fund ambulatory training

25

26

27

10

28

29

The Flipped Healthcare Classroom 2017…

• The Patient Will See You Now

• DPCP

• Retail Clinics

• Telehealth

• Digital Media Resources

• Home Hospital

• Patient Wearables, etc…

30

11

31

32

How Did We Get Here? The Alliance of Acronyms…

33

12

What’s Missing From The Triple Aim?

34

What is the one professional challenge that concerns you most?

Challenge Percent

Limited time with patients 14.5

Too much paperwork 11.9

Work/life balance 11.8

Loss of physician autonomy 10.7

Physician burnout 6.9

Maintenance of certification (MOC) 5.8

Malpractice threats/need to practice defensive medicine 5.6

Staying current on clinical knowledge 5.5

Electronic health records (EHRs) 4.7

Physician reimbursement and payment issues 4.1

Source: ACP 2015 Member Survey 35

At the Pediatrician’s Office: Where’s My Doctor?

• The present? The future?

© 2011 Thomas Murphy, MDSource: JAMA 2012;307:2497-8Used with permission.

36

13

http://annals.org/aim/article/2614079/putting-patients-first-reducing-administrative-tasks-health-care-position-paper

37

38

What does this practically mean for your practices?

• The number 1 thing that can be done to improve physician satisfaction with practice is to ease unnecessary regulations and tasks.

• Patients will also benefit as their physicians are able to spend more time with them with less distraction.

• Making EHRs more clinically relevant and useful requires that we examine and simplify the embedded federally‐mandated documentation requirements.

• We also need an entirely new way of looking at administrative tasks, to assess their intent, impact and possible alternatives.

39

14

40

Source: California HealthCare Foundation 41

Strategies To Reduce Burnout

• Align leadership values with clinicians’ values– Leaders model work‐home balance; value well‐being – Understand and promote work control– Alter our “culture of endurance”

• Support work‐home balance– Support needs of parent clinicians– Offer flexible/part‐time work options

• Wellness focus – reflection, exercise, share concerns with colleagues

Linzer et al. Acad Med 2009;84:1395‐1400; Saleh et al. Clin Orthop Relat Res 2009;467:558‐65; Viviers et al. Can J Ophthalmol 2008;43:535‐46; LeMaire J. BMC HSR. 2010; 10:208

42

15

Make internal medicine practice more satisfying…

• Clinical documentation

• EHRs: functionality, usefulness, clinical relevance

• Patients Before Paperwork ( Captures all of ACP’s activities to reduce administrative burdens)

• Payment reform: pay more for cognitive care, chronic care

• Quality measures: relevance, burden of reporting

43

Have Empathy and Each Day Do Something for Another

44

An All Too Familiar Patient…

A 40 year old patient with type 2 DM on insulin presents to the clinic (substitute ED) for the 4th

time in 3 months with a blood sugar ~400. VS are stable, PE shows no signs of dehydration, trace ketones and 4+ glucose in UA, BMP nlexcept for BS 425.

What do you think could be going on?

45

16

46

47

Stemming The Escalating Costs of Prescription Drugs‐ A Classic Case of

Grass Roots Advocacy• Several years ago, several members of an ACP Chapter brought this topic to their Health and Public Policy Committee

• The ACP Chapter submitted this as a resolution to the ACP Board of Governors for policy development

• The Board of Governors and Board of Regents passed the resolution

• In 2016, this became policy for the ACP

48

17

49

50

Impact of Obamacare in Four Maps, The Upshot, New York Times. October 31, 2016. http://www.nytimes.com/interactive/2016/10/31/upshot/up-uninsured-2016.html?action=click&contentCollection=upshot&region=rank&module=package&version=highlights&contentPlacement=1&pgtype=sectionfront&smid=tw-upshotnyt&smtyp=cur

51

18

http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-november-2016/?utm_campaign=KFF-2016-November-Tracking-Poll&utm_content=48711492&utm_medium=social&utm_source=twitter

52

53

Who loses if insurers can again waiver coverage or charge more for preexisting conditions? Your patients.

54

19

In 2002, an Institute of Medicine review concluded that lack of insurance increases mortality, but several relevant studies have appeared since that time. This article summarizes current evidence concerning the relationship of insurance and mortality. The evidence strengthens confidence in the Institute of Medicine's conclusion that health insurance saves lives: The odds of dying among the insured relative to the uninsured is 0.71 to 0.97.

Woolhandler S, Himmelstein DU. The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?. Ann Intern Med. [Epub ahead of print 27 June 2017] doi: 10.7326/M17-1403

55

Travel ban: health impact

56

These IM residents (ACP members) were prohibited from re‐entering the US because of the Executive Order

57

20

ACP: A Global Community

• International chapters: Bangladesh, Brazil, Caribbean, Canada (6), Central America, Chile, Colombia, India, Japan, Mexico, Saudi Arabia, Southeast Asia, and Venezuela

Over 14,000 ACP members reside outside the United States

58

Big wins for advocacy! Courts block insurer mega‐mergers

59

All in month’s work: 30 days of ACP advocacy: September 6 to October 6,

2017• Spoke out on Hate Crimes as a Public Health Issue

– September 5 statement on Charlottesville https://www.acponline.org/advocacy/acp‐advocate/issue/article/726073

• Defended “Dreamers”

– September 5 statement on President Trump’s decision to end DACA https://www.acponline.org/advocacy/acp‐advocate/issue/article/726647 , letter to Congress in support of DREAM Act https://www.acponline.org/acp_policy/letters/joint_letter_to_congressional_leaders_supporting_dreamers_2017.pdf and joint letter https://www.acponline.org/acp_policy/letters/joint_letter_to_congressional_leaders_supporting_dreamers_2017.pdf

60

21


2017• Advocated for Safety‐Net and Primary Care Training Programs

– September 5 Joint Letter to Congress https://www.acponline.org/acp_policy/letters/joint_letter_to_congress_supporting_extension_of_safety_net_programs_2017.pdf

– September 28 coalition letter to Congress https://www.acponline.org/acp_policy/letters/letter_to_house_and_senate_leaders_on_ex

piring_primary_care_workforce_programs_2017.pdf and ACP letter https://www.acponline.org/acp_policy/letters/letter_to_house_and_senate_leaders_on_expiring_primary_care_workforce_programs_2017.pdf

• Advocated to Reverse Cuts in Medicare payments to Clinical Labs– September 11 sign on letter to CMS,

https://www.dropbox.com/s/0hjl1bxl0um9fmy/PAMA%20POL%20Letter%20Aug%202017%20final.pdf?dl=0

61


2017• Advocated for Better Medicare Payments for Internists’ Services

– September 11, Comments on Medicare Physician Fee Schedule https://www.acponline.org/acp_policy/letters/comment_letter_to_cms_re_cy_2018_medicare_pfs_proposed_rule_2017.pdf

• Advocated for Better Quality Measurement– September 14 “Friends of NQF” letter urging continued mandatory funding for

NQF’s quality and measurement work https://www.acponline.org/acp_policy/letters/joint_letter_to_speaker_ryan_supporting_nqf_funding_2017.pdf

• Spoke Out Against Discrimination– Opposed President Trump’s decision to ban Transgender persons from military;

Sent two letter on September 14 letters in support of bills to overturn it https://www.acponline.org/acp_policy/letters/letter_to_senators_gillibrand_and_collins_supporting_transgender_servicemembers_amendment_2017.pdf and https://www.acponline.org/acp_policy/letters/letter_to_senators_mccain_and_reed_supporting_transgender_servicemembers_amendment_2017.pdf

62


2017• Supported Legislation to Lower Prescription Drug Prices

– September 19 joint letter supporting CREATES Act, “For too long, brand‐name pharmaceutical manufacturers have exploited patient safety tools in order to stifle generic competition and attendant lower prescription drug prices.”https://www.acponline.org/acp_policy/letters/joint_letter_to_senate_leadership_supporting_creates_act_2017.pdf

• Proposed policies to improve the Medicare Advantage Program

– New position paper published on October 2 with recommendations to bring introduce greater transparency and impose fewer administrative demands on clinicians in the MA program. https://www.acponline.org/acp‐newsroom/american‐college‐of‐physicians‐says‐medicare‐advantage‐should‐increase‐transparency‐align‐and‐reduce

63

22


2017• Advocated to protect access to health care for women including opposing

proposals to defund Planned Parenthood, eliminate coverage for contraception and other essential benefits.

– September 22 joint coalition letter to Congress https://www.acponline.org/acp_policy/letters/joint_womens_health_providers_coalition_letter_to_senate_opposing_graham_cassidy_2017.pdf

– October 6 letter opposing interim final rule to allow employers to waive contraception coverage https://www.acponline.org/acp‐newsroom/american‐college‐of‐physicians‐objects‐to‐overhaul‐of‐contraception‐mandate

• Countered the administration’s decisions to reverse commitment to mitigating health impact of climate change.

– Updated climate change action kit available at this meeting reflects latest evidence, proposes actions to counter the administration’s decision to pull out of Paris Accord and other commitments https://www.acponline.org/advocacy/advocacy‐in‐action/climate‐change‐toolkit

64


2017• Called for improved disaster relief response for Puerto Rico and U.S. Virgin

Islands

– September 28 letter to the President https://www.acponline.org/acp_policy/letters/letter_to_president_trump_urging_additional_hurrican

e_relief_support_for_puerto_rico_usvi_2017.pdf, continually updated resources for members https://www.acponline.org/acp‐newsroom/supporting‐hurricane‐aid‐efforts

• Advocated to Improve Medicare’s Quality Payment Program (MACRA)

– Signed onto October 2 letter organized by AMA seeking targeted legislative fixes. https://www.dropbox.com/s/hnsk73phmljlpge/MACRA_EAC%20‐%20Final%20Letter.pdf?dl=0

– Builds on ACP’s previous comments to CMS.

65


2017• Led the effort within American medicine, in alliance with

broader health care community, to stop efforts repeal the ACA and rollback coverage and protections for millions of patients. Sixteen letters from ACP, or ACP and our coalition members, in the last month alone!

66

23

Part of the EHR solution: simplify documentation requirements

Reworking Evaluation & Management (E/M) Documentation Guidelines:

Based on Clinical Documentation in the 21st Century the College has held numerous

meetings with the deputy administrators at CMS and other agencies within HHS

regarding reducing the administrative burden of the E/M documentation guidelines.

– On June 28, 2017 ACP attended a meeting with HHS where the College outlined a

proposal to move forward with reform of E/M documentation guidelines.

– This has led to Solicitation of Public Comment on the reform of the E/M

documentation guidelines through the 2018 Medicare Physician Fee Schedule

NPRM.

– ACP will provide detailed comments and recommendations for simplification and

alignment of E/M documentation through the rulemaking process

Link to paper: http://annals.org/aim/article/2089368/clinical‐documentation‐21st‐century‐executive‐summary‐policy‐position‐paper‐from

67

Expand access and coverageImprove public healthSupport research and scienceOppose discriminationReduce health care disparitiesSupport primary care workforce

Lower excessive Rx pricesReform and improve paymentsImprove quality measuresReform medical liability systemMake EHRs work for doctorsReduce crushing administrative burden

ACP’s “Big Tent” advocacy agenda addresses a wide range of issuesaffecting internists and their patients . . .

And whatever else pops up!

68

69

24

Resources for Educators

• Teaching Medicine SeriesTheory and Practice of Teaching Medicine, Teaching Methods, Teaching in the Hospital, Teaching in the Clinic, Teaching Clinical Reasoning, Mentoring in Academic Medicine, and Leadership in Medical Education

• Annals of Internal Medicine teaching tools • Internal Medicine In‐Service Training Examination for

residents• ACP Board Prep Curriculum for residents• High Value Care Curriculum for trainees at all levels• IM Essentials for medical students

70

Recent ACP Policy Papers

• Addressing the Increasing Burden of Health Insurance Cost Sharing (July 2016)

• Financing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of Physicians (May 2016)

• Climate Change and Health: A Global Call to Action (April 2016)

• Stemming the Escalating Cost of Prescription Drugs (March 2016)

• Medicaid Expansion: Premium Assistance and Other Options (March 2016)

71

Advocates for Internal Medicine Network (AIMn)

• Grassroots advocacy network designed to help ACP members engage with federal lawmakers on policy issues important to internists

• AIMn members receive legislative updates and alerts as key policy issues unfold, including sample messages to members of Congress

• Enroll at https://cqrcengage.com/acplac/

• To learn more, contact Shuan Tomlinson:• Tel: 202‐261‐4547

• Email: [email protected]

72

25

ACP’s New Online Learning Center

• Available at ACPOnline.org/OLC• Enhanced search and browsing

functionality for ACP’s online learning• Easy access to more than 350 activities,

including:– Video‐based learning– Webinars– Interactive cases– Quizzes

The majority of activities offer both CME and MOC.

A centralized gateway for ACP’s online learning activities

ACPOnline.org/OLC

73

Resources to Help You Transform Your Practice: Prepare for New Payment

SystemACP is helping you transform your practice, choose the right path, keep up‐to‐date and meet deadlines through tools and resources: (ACPOnline.org/MACRA)• MACRA/QPP Information: Online FAQs, fact sheets, webinars

(live and recorded), articles in ACP publications • Practice Transformation: Information, resources, tools to support

practices in making strategic changes to successfully care for patients in the value‐based payment environment

• New: Quality Payment Advisor: Online tool to assist practices in determining the best path to take—MIPS or APM.

• ACP Practice Advisor: Online tool to help practices analyze and improve patient care, organization and workflow

• Physician & Practice Timeline: Online tool helps track deadlines for regulatory, payment, educational and delivery system changes and requirements. Members can sign up by texting ACPtimeline(no space) to 313131 from mobile phones

74

ACP’s Main Website for the QPP

www.acponline.org/qpp 75

26

Encouraging High Value Care

Resources to help provide the best patient care while reducing health care costs: • High Value Care Online Cases: Earn free CME credits and MOC

patient safety and medical knowledge points through web‐based cases and questions

• Curriculum For Educators, Residents and Students: Created by ACP and the Alliance for Academic Internal Medicine (AAIM), features six one‐hour interactive modules

• HVC Course For Medical Students: Students evaluate the benefits, harms and costs of tests and treatment options so they can make HVC a reality in clinical practice

76

Encouraging High Value Care (cont’d)

Resources to help physicians provide the best patient care while reducing costs to the health care system:• High Value Care Coordination (HVCC) Toolkit: Resources to

facilitate more effective and patient‐centered communication between primary care and subspecialist doctors.

• Pediatric to Adult Care Transitions Toolkit: Resources to facilitate more effective transition and transfer of young adults from pediatric to adult care.

• Collaboration with Consumer Reports: A series of new High Value Care Resources to help patients understand the importance of seeking appropriate care.

77

78

27

Support the Next Generation of IM

• Encourage a young person to understand the rewards of internal medicine as a career

• Convince a medical student to see the bright future of internal medicine

• Recommend general internal medicine to a resident

• Invite another internist to become an ACP member

• Sponsor a qualified ACP Member for Fellowship (FACP)

79

ACP . . . Get Connected

• MyACP 2.0 –a personalized web experience, making it easier for members to access and discover pertinent ACP content and resources while visiting ACPOnline.org.

• ACP Member Forums

ACP Member Forums allow ACP members to instantly participate in discussions on a range of clinical, professional, and practice‐related topics.

• Join your local IM community through ACP Chapters

– Network, gain CME, develop leadership skills

– Mentor medical students and early career physicians

• Develop skills through the ACP Engagement Program

– Volunteer to help in development of ACP products

– Judge abstracts and mentor early career physicians

• Follow on social media

ACP and Annals of Internal Medicine are using social media more than ever to communicate and share information relevant to internal medicine.

80

Internal Medicine Meeting 2018:ACP’s Annual Scientific Meeting

Internal Medicine Meeting 2018April 19‐21, 2018New Orleans

Register online at https://im2018.acponline.org/

• Over 200 educational, interactive workshops and case‐based sessions and feedback on patient management problems taught by speakers

• Networking events including Women’s Networking luncheon, African American Reception and various early career events

81

28

Thank you . . .

…for your continued support of ACP and your commitment to internal medicine.

82

1

Representative Gregory F. Murphy, MD, FACSNC House of Representatives

1

NC Legislative Medical Issue Update 2018

2

Brief Overview of Politics

Versus

Legislative Branch Executive Branch

US

State

3

2

Judicial BranchSupreme Court

Essentially the ultimate decision makers

4

How are laws made?

• Issue brought up by constituent, business group, society (NCMS), environmental group, state gov agency, anyone

• Bill drafted with assistance of Staff Attorneys and then submitted to the Speaker of the House

• Assignment of Bills…Very Important…• If viewed favorably by leadership, good assigment• If not viewed favorably, often sent to the Rules Committee where bills

usually die

5

6

3

Committee Meetings

7

Floor DebateFloor Debate

Each Bill has to be voted on THREE times on three separate days (rare circumstances…HB2)

Sometimes debate quick and noncontroversial, others debate well into the night…

Majority Party usually gets its way if issue controversial

Once a Bill passed in the House it is sent over to the Senate for the WHOLE process to start over (Committee Assignment, etc)

Bill can die there, be changed mildly or substantially

8

Final Stages of a Bill

Governor signs into Law

Governor Vetoes

Unfortunately still can be very partisan

9

4

10

Historical Political Involvement by Physicians

*In 1776, 11 percent of signers of the Declaration of Independence were physicians.

*In 1787 5 percent of the individuals crafting the US Constitution were physicians.

113th Congress (2013 – 2015)From 2013‐2015 there were 21 physicians in U.S.Congress, 20 of whom were male and 17 were members of the Republican party.114th Congress (2015 – 2017)From 2015‐2017, there were 18 physicians in U.S. Congress. All were male and 15 were members of the Republican party. (38% Lawyers)115th Congress (2017 – 2019)From 2017‐2019 there were 15 physicians in U.S. Congress, all were male and 13 were members of the Republican party. (3% Physicians)

Neal Dunn, MD (R), 2017‐2018 US Congress2nd District Florida

11

12

5

13

14

15

6

Legislative Successes

16

Senate Bill 33 2011Malpractice Reform

17

North Carolina Senate Bill 332011

Caps on noneconomic damageSB 33 caps compensation for noneconomic damages at $500,000. “Noneconomic damages” refers to compensation for pain, suffering, personal loss, professional loss or anything else that cannot be defined monetarily.

Immunity for emergency personnelIn addition to the cap, SB 33 gave extra protection to emergency personnel by putting tougher standards to prove medical malpractice in an emergency situation. Plaintiffs must prove “gross negligence” when pursuing a malpractice case classified as an emergency.

18

7


Almost didn’t happen:Although passed in Senate and then in House BUT—Vetoed by Governor Bev Perdue

NCMS and other Stakeholders went into actionurging physicians to visit their legislators and made their voices heard one on one

Veto Overridden!!! 74‐42

Physician Advocacy Works!!!!!

19


Results:

55‐65% decrease in malpractice cases since 2011

Stabilization of Malpractice RatesMedical Mutual Investment Program

2014 marked the second consecutive year that malpractice payout amounts in the U.S. rose, according to Diederich Healthcare. However, North Carolina was one of four states in which payouts fell.

IN NC a total of $44,009,050 was paid in med mal claims in North Carolina in 2014 –28.67 percent less than in 2013.

20

21

8

NC House Bill 243“STOP ACT”

Opioid Epidemic in NC*4 die from Opioid Overdose each day in NC*1:100 babies born addicted to Opioids*Wilmington, NC #1 worst city in US (NC w 4 out of top 15)

SOMETHING had to be done*State Attorney General, other non‐

medical Legislators draftedup initial Legislation

*First Draft VERY burdensome to physicians

*Made sure a physician at the table to direct the

Legislation22

Physician Leadership in LegislationHouse Bill 243

23

NC House Bill 243

Initial restriction of 3 day script for Opioids*Would have been exceedingly bothersome for MD’s*Subsequently changed to 5 day restriction for Acute Pain*Post Op pain to 7 days

Required Queries of Controlled Substance Reporting System (CSRS) with each Narcotic prescription to check patients history

*Must document in EHR*Had to explain what limitations EHR’s have*Allow paper script to be used at times

Attorney General wanted to fine MD’s $250 for each instance *CSRS not queried

*Changed language to reporting to NCMB—no fine

Initially a yearly fee of $50 per doc to keep CSRS going*Negotiated that down to $20 24

9

Initial prescription limits for ACUTE PAINCSRS Queries with each prescriptionEscribing of OpioidsWork RequirementCloser consultation with NP’s/PA’s/MD’s at Pain ClinicsBetter defined disposal of Prescribed Opioids (Hospice)Standing Order for NaloxonePharmacy Reporting with CSRS and regulationsMandatory yearly review of CSRSOver $30 Million dollars secured for Community

Substance Abuse treatment.

STOP ACT SUMMARY

25

Playing Defense

26

Playing Defense….House Bill 36

Bill to allow Optometrists to perform Laser Surgery in their Offices

Optometrists hired $750K worth of Lobbyists

Would have had profound implications if passed

As a Chair able to get it blocked completely and turned into a ‘study bill’, then died in Senate….(for now anyway)

27

10

Scope of Practice IssuesHB 88

HB 88 seeks to allow NP’s, CRNA’s and Midwives to practice without supervision.

Would fundamentally change the way Health Care is delivered in NC

28

Defense: Motor Cycle Helmet Law

Would have allowed persons 21 years and older to no longer be required to wear helmets

29

30

11

31

Other insanities….

Require out of network payments to be equal to Medicare only

“Assignment of Benefits” issue…

Allow Chiropractors to do Sports Physicals…

HB 36 and HB 88 not dead….

32

33

12

34

35

Carolina Cares HB 662

36

13

Carolina Cares HB 662

Key ComponentsAlternative to Medicaid Expansion

Health Insurance for the State’s Working Poor

Participant’s required to do health maintenance activities

Paid for by Fed return of monies to state and tax on Hospitals (2:1 return)

Participant Contributions2% of household’s income

Required

Future Unclear…..

37

So again…why did I agree to do this?....

The only physician in our entire General Assembly….

Health Care Crisis the #1 domestic issue facing our state and our nation

38

The Bottom Line…..

#1 Comment when Controversial Medical issue comes up

“I never hear from doctors unless they want something”

You have to get to know your Legislator and you MUST Contribute to their campaigns.

39

1

Treatment of Opiate Addiction: What Do We Do Now?

Michael Lang MD

Clinical Associate Professor

Internal Medicine and Psychiatry

1

Objectives

• Explore the extent of substance abuse disorders in the prescription drug population

• Identify problematic behaviors indicating substance abuse, drug seeking in the clinical setting

• Explain the diagnostic criteria for opiate abuse/dependence diagnosis

• Compare/contrast treatment measures for opiate dependence

2

What is the Risk of Addiction?

From a systematic review from 38 studies – rates of misuse, abuse, and addiction in chronic pain

Misuse rates: 21‐29%

• Opioid use contrary to the directed or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects.

Addiction rates: 8‐12% • Pattern of continued use with experience of, or demonstrated potential for,

harm (ex: “compulsive use; continued use despite harm, and craving”).

Source: Vowles KE, et al, Pain 20153

2

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Deaths per 100,000

population

Year

Motor Vehicle Traffic (Unintentional)

Drug Poisoning (All Intents)

α β

Death Rates* for Two Selected Causes of Injury, North Carolina, 1968‐2015

*Per 100,00, age‐adjusted to the 2000 U.S. Standard Populationα ‐ Transition from ICD‐8 to ICD‐9β – Transition from ICD‐9 to ICD‐10 National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset

Source: Death files, 1968‐2015, CDC WONDERAnalysis by Injury Epidemiology and Surveillance Unit

1989 – Pain added as 5th Vital Sign

Drug Overdose Deaths on the Rise

The extent of the addiction

Cicero, et al, 2014 Muhuri, et al, 2013

5

One‐and 3‐year probabilities of opioid use by duration of first episode in days

Acute Pain Treatment Leading to Long Term Use4

CDC Weekly March 17, 2017 / 66(10); 265‐269 “Characteristics of Initial Prescription Episodes and Likelihood of Long‐Term Opioid Use — United States, 2006–2015”

6

3

Risk Stratification Prior to Prescribing

7

Lower Risk Medium Risk Higher Risk

Etiology of Pain

Clear/Identified Vague/Non‐specific

Substance Abuse

Negative history Past history but

stable recovery

Active abuse or

addiction

Psychiatric Conditions None Few / Stable Multiple / Unstable

Environment Stable/Supportive/

Resources

Unstable/Few supports/

Few resources

Activity

Engagement

Employed/Active

Active self‐mgmt/

Uses non‐med modalities

Unemployed/Inactive

Poor self mgmt/

Emphasis on med only

CSRS

Initial Drug Screen

One prescriber/Low dose/No benzo.

C/W prescription history/No illicit drugs

One prescriber/Moderate dose/Benzos

>1 prescriber/High dose/Benzos/Irregularities

Not c/w prescription history/Illicit drugs

Signs of Opioid Intoxication

Physical

Pupillary Constriction

Slurred Speech

Drowsiness

Impaired Attention

Respiratory slowing

Bradycardia

Pulmonary Edema

Coma

Psychiatric

Euphoria (esp at onset)

Apathy

Dysphoria

Psychomotor agitation (onset)

Psychomotor retardation (later)

Impaired judgement

8

Risk Assessment Tools

9

4

Quantifying Function & Risk

• Pain scales• BPI, McGill Pain Questionnaire, PEG• Back Pain Functional Scale (BPFS)

• Psychiatric scales• PHQ‐9, PHQ‐4, GAD‐7

• Substance use evaluation• ORT or other scales• ETOH use• Smoking

• Aggregate data represented as single number

• Consider developing predetermined treatment actions for particular scores

Passik, Weinreb. 199810

Merrill and Duncan 2014 11

Dependence vs. Addiction

• Physical dependence is characterized by tolerance and withdrawal

• A patient can be dependent on a drug without being addicted

• Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental influences

• Aberrant behaviors: Loss of control, compulsive use, continued use despite harm, craving

12

5

Opioid Use Disorder (DSM‐V)• Taken in larger amounts or for longer periods

• Persistent desire/unsuccessful efforts to reduce usage

• Great deal of time spent obtaining/using opioids

• Craving, or strong desire to use opioids

• Failure to fulfill work/home obligations due to opioid use

• Lack of concern for problems due to recurrent opioid use

• Lack of interest in activities that used to be important

• Recurrent use of opioids despite hazards

• Continued use despite known problems due to opioid use

APA DSM 5 workgroup 201313

Opioid Use Disorder (DSM‐V)• Tolerance (except for those under medical supervision)

• Markedly increased amounts to achieve desired effect

• Markedly diminished effect with continued use at same amount

• Withdrawal (except for those under medical supervision)• Characteristic opioid withdrawal syndrome

• Opioids are taken to relieve or avoid withdrawal syndrome

Mild OUD: 2‐3 CriteriaModerate OUD: 4‐5 CriteriaSevere OUD: >6 Criteria

APA DSM 5 workgroup 2013

14

Communication About Addiction

• Focus on “benefits/risk” mindset

• Address patient behaviors which raise concerns about abuse (running out, “lost” scripts, etc.)

• Remember that patients may suffer from both chronic pain and addiction

• Intervention based on level of risk and concern for safety: “I cannot responsibly continue prescribing opioids because I feel it would cause more harm than good”

• Always offer referral to treatment

• May need to abandon risky treatment, but not patient.• Maximize non‐opioid treatment options

Merrill, Duncan 2014

15

6

Does My Patient Need to Stop?

Criteria to consider discontinuing long‐term opioid therapy: Inability to achieve or maintain expected pain relief or functional improvement despite dose escalation• Intolerable adverse effects at the minimum dose that produces effective

analgesia• Persistent non‐adherence with patient treatment agreement• Deterioration in physical, emotional or social functioning attributed to

opioid therapy• Resolution or healing of the painful condition

Berna, et al. 201516

Does My Patient Need to Taper?

• Use shared decision making as much as possible in planned taper; set expectations

• Individualize tapering plans based on patient goals, concerns, and length of time on opioid therapy

• Speed of taper depends on level of concern vs. apparent risk of harm (consider detox trt at this point)

• Build up alternative pain treatment modalities

• Consider treatment for substance use disorder if present

• Communicate clearly with patient and document plan

Berna, et al. 201517

Opioid Overdose Reversal: Naloxone HCL

• Mu‐opioid receptor antagonist

• Can’t get ‘high’ from it (no potential for abuse)

• Quick acting, acts in 3‐5 minutes

• Delivered via injection 0.4 mg (IM, SC, IV) or nasal 2/4 mg

• NC: no prescription required under standing order

• www.naloxonesaves.org

18

7

ASAM Guideline

• Developed to guide management for opiate overdose and treatment of opiate use disorders

• Diagnostic recommendations (Part 1)• History and assessment of behavior• DSM 5 criteria• Quantify using a validated scale

• Objective Opioid Withdrawal Scale (OOWS)• Clinical Opioid Withdrawal Scale (COWS)

• Urine drug screens• Type of screen, cost are considerations

Kampman, Jarvis 2015 19

ASAM Guideline

• Comprehensive assessment (part 1)

• Full medical history & exam• Focus on Hepatitis, HIV, TB, acute trauma, pregnancy

• Identify co‐morbid psychiatric disease

• Full substance use history• Concurrent use etoh, sedatives, hypnotics, anxiolytics

• Tobacco use

• Identify facilitators and barriers to treatment

Kampman, Jarvis 201520

Social/Environmental Factors

• Barriers• Government regulations

• Insurance costs

• Lack of Pharmaceutical industry interest

• Provider education/experience

• Treatment philosophy

• Logistical issues

• Lack of patients awareness

Oliva, Gordon 2011

21

8

Part 2: Select the Appropriate Level of Care


Part 3: Manage Opiate Withdrawal

Koston, George. 2002 Kampman, Jarvis 2015 23

Opiate Detoxification

• Four commonly used strategies• Methadone substitution

• Clonidine

• Clonidine/Naltrexone combination

• Buprenorphine

• Little risk of adverse medical consequences

• Goals• Stabilization

• Preparation for long term treatment


9


Methadone Substitution

• Long duration action• Smoother transition

• Start at 20‐40mg/day• Lethal in non addicts

• Adjust dose over next few days based on symptoms

• Adjust 10‐15% per week

• Advised only for use in highly addictive items

• Heroin, Demerol

Clonidine• Alpha receptor agonist

• 0.1‐0.3 q6‐8 hrs

• Serves to reduce sympathetic output• Fast heart rate, BP• N/V/D/belly cramps• Sweats, chills

• Most common side effects• Sedation low BP

• For less addictive items• Codeine, Oxycodone

Fishbain et al 2011 Kampman, Jarvis 2015 25


Clonidine/Naltrexone

• Combo addresses shortcomings of clonidine

• Shortens time to detox• Often 2‐3 days

• First 8 hours can be risky• Naltrexone can cause massive w/d and lower BP

• May need meds for cramps• Alternative to Methadone

Buprenorphine

• Partial mu agonist• Previously only by injection

• Suboxone is outpatient mainstay

• Very Safe• Ceiling effect

• Blocks cravings • Blocks rewards• Some potential for abuse

Fishbain et al 2011 Kampman, Jarvis 201526

Opiate Treatment After Detox

• Coping strategies for stress are critical to long term abstinence

• Many of same drugs used for detox are adjusted for abstinence• Methadone maintenance

• Suboxone clinics

• All MAT options must be accompanied by case‐appropriate psychosocial interventions to achieve best outcome


27

10

Can Psychosocial Intervention Truly Benefit?

• Kentucky Medicaid Wellcare Initiative

• 1300 members identified as high risk• Connected to 1 pharmacy, 1 provider, 1 care manager

• Care manager set up required engagement in community services• Counseling, social services, exercise

• Results• 50% reduction opiate prescribing

• 35% drop in cyclobenzaprine prescribing

• 30% drop in benzodiazepine prescribing

Walker 201728

The Therapy Component

• Group & Individual Therapy• Critical for relapse prevention

• Address psychological, social factors

• No one approach is best for all patients

• In general group > individual

• Group allows for peer support, guidance

• Individual best for focus on co‐morbid dx

• Most evidence based interventions

• Cognitive behavioral therapy

• Motivational interviewing

• Contingency management

• Harm reduction

• 12 step facilitation/12‐step programs

• Relapse prevention

Dutra et al 2008Merrill, Duncan 2014

29

Detox to Maintenance: Buprenophine

30

11

Methadone Maintenance• 40 years of clinical data

• Still significant stigma

• Separated from other med settings

• Duration 24‐36hrs• Given dose to prevent w/d

• Urine screens frequently

• Daily dosing

• Target dose 60‐120mg

• Visit frequency on continuum

• Given in licensed facility only!

Merrill, Duncan 2014Fullerton, Kim, Thomas 201431

Naltrexone

• Originally designed for opiate addiction

• Also blocks reward of alcohol effect on enkephalins

• Can see effect within 7‐10 days

• 60% response rate

• Serious side effects rare• Liver injury

• Best choice‐motivated pt, short hx of abuse

• Extended release injection if adherence is a concern

DeWitt, et al 2005. Kampman, Jarvis 201532

The Multimodal Team

33

12

Substance Abuse & Psychiatric Co‐Morbidity

34

Kessler, 2000

Psychiatric Co‐morbidity of SA

• Most prevalent psychiatric disorders in US:• Substance use disorders

• Mood disorders

• Anxiety disorders

• These tend to merge with time

• Any & all require attention & possible treatment

Anxiety Mood

SUD

Co‐Morbidity: The Chicken or The Egg?

• Given a substance dependent patient• Comorbidity is the norm• Although not absolute

• Faced with a chronic substance abuser endorsing psychiatric symptoms• Did drug induce the problem?• Did problem predate the drugs?

• Self medicating

• First verify safety• Substance treatment facility vs. behavioral health unit

• Monitor carefully for drug‐drug interactions

• Consider ACT teams for these patients


13

Substance Abuse & Chronic Pain• Can be very difficult to tease out• Standard is to treat objectively‐ verify diagnosis

• Exam findings• Labs, X‐Rays

• Take substance abuse history into account• NSAIDs, acetaminophen if feasible• Ideally stop buprenorphine and use high potency opiate

• If needed realize dosing will need to be higher given tolerance

• If active opiate use disorder & not in treatment‐methadone, buprenorphine

• Allowable with close scrutiny‐especially if outpatient setting

• Pain contracts• Frequent re‐evaluation and treatment


Special Population: Pregnancy

• Medical evaluation (status of pregnancy) and psychosocial assessment 1st

• GYN involved early• HIV, Hepatitis, other STDs

• Position on reporting substance use in pregnancy• Given pregnancy proceed to maintenance rather than withdrawal management

• Methadone preferred• Buprenorphine second line• Avoid naloxone unless in setting of OD

• Have a low threshold for hospitalization especially in 3rd trimester

38

Special Population: Adolescents

• Psychosocial treatments are mandatory and vital• Should be instituted first and maintained• Often teens are seen in more specialized facilities with multimodal services

• The full spectrum of pharmacotherapy options should be considered

• Methadone and buprenorphine included

• A special focus of health maintenance should be STD risk reduction

Kampman, Jarvis, 201539

14

Special Population: Criminal Justice System

• MAT has been shown to be effective in correctional setting

• Just as in other setting psychosocial treatment should work as adjunct to MAT

• No one medication option is show as superior or safer

• MAT should be maintained especially once paroled• Should be started minimum 30 days prior to release

• Structured follow‐up must be in place


40

New Horizons‐ Separating Analgesia from Addiction

NKTR‐181

• Phase 3 trials currently for mod‐severe chronic pain

• Low permeability/slow entry across BBB

• Reduced effect on dopamine release

• 42 recreational drug users• 3 doses of NKTR vs. Oxycodone 40mg

• Drug liking score sig lower for all but 400mg dose

CR845

• Selectively activates K‐opioid receptor (KOR)• No activity at mu receptor• Can’t cross BBB

• Given IV for lap hysterectomies and bunionectomies

• 4 way x‐over design for 44 recreational drug users• Placebo, 5mcg/kg CR8, 15mch/kb CR8, 0.5mg/kg

Pentazocine• Drug liking scores sig best for Pentazocine, placebo and

CR8 essentially equal

Bender, July 2017 41

New Horizons‐ NSS‐2 Bridge Neurostimulator

• FDA approved November 2017• 73 patients 5 treatment centers• Withdrawal scale scores dropped 63% after 20 min of use compared to sham

• 88% pts successfully moved to MAT• Based on concept of auricular acupuncture

• Intended for short term use only• Battery dies after 120 hours• 2nd Rx for those transitioning off methadone

• No significant adverse effects for duration of therapy

Zagorski 201842

15

Clinicians should consider offering naloxone to which of the following patient groups?

• History of opioid overdose

• History of substance use disorder

• Higher opioid dosages (≥50 MME/day)

• Any dose of an opioid + benzodiazepine

• All of the above

Coffin P, et al 2016

43

Chronic pain patients with current opioid addiction can get the best benefit from which of the following interventions?

• Detoxification from opioids followed by opioid analgesic therapy

• Buprenorphine treatment along with behavioral interventions

• Methadone taper followed by naltrexone

• Benzodiazepine and SSRI combination


44

A Few Final Points

• Opioid use disorder is a chronic, potentially fatal, but treatable condition associated with a significant genetic predisposition that is on the rise.

• Keep diagnostic criteria in mind and engage patients early

• MAT with buprenorphine, methadone or naltrexone reduces mortality and improves health & social outcomes

• Federal and state regulations draw sharp distinction between use of opioids to treat pain vs. opioid use disorder.

• DEA‐registered MD, PA, NP may access free training to qualify for DATA 2000 waiver to prescribe buprenorphine for opioid use disorder.

45

16

Thank You For Your Attention

Questions or Comments

46

• Chang, H.‐Y., Daubresse, M., Kruszewski, S. P., & Alexander, G. C. (2014). Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. The American Journal of Emergency Medicine, 32(5), 421–431. https://doi.org/10.1016/j.ajem.2014.01.015; Daubresse, M., Chang, H., Yu, Y., Viswanathan, S., Shah, N. D., Stafford, R. S., … Alexander, G. C. (2013). Ambulatory Diagnosis and Treatment of Nonmalignant. Medical Care, 51(10), 870–878.

• Teater D. Evidence for the Efficacy of Pain Medications. Itasca, Illinois; 2014. http://media.wix.com/ugd/cb52b5_8a3726bdfc2c47fa9da81547e622cb45.pdf;

• Moore RA, Derry S, McQuay HJ, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database Syst Rev. 2011;9(9):CD008659. doi:10.1002/14651858.CD008659.pub2.

• Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long‐Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66(10):265‐269.

• Passik & Weinreb, Four A’s of Pain, 1998

• Vowles KE et al Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis Pain. 2015. https://www.ncbi.nlm.nih.gov/pubmed/25785523

• Tapering Long‐term Opioid Therapy in Chronic Noncancer Pain, Berna C, et al. Mayo Clin Proc. 2015. http://www.mayoclinicproceedings.org/article/S0025‐6196(15)00303‐1/pdf

References

47

References• Zagorski, Nick. FDA Clears Way for Stimulation Device to Treat Opioid Withdrawal Symptoms. Psychiatric News. Vol 53, Num 1. January 5, 2018. p 20.

• Bender, Kenneth. Opioid Research Seeks to Separate Analgesia from Addiction. Neurology & Psychiatry. Vol 7, issue 4. July, 2017. p 25‐26.

• Kampman, K. Jarvis, M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addiction Med. Vol 9, Num 5. Sept/Oct 2015 p358‐367.

• Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821‐826

• ‐Muhuri PK, Gfroerer JC, Davies MC; Substance Abuse and Mental Health Services Administration. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical‐pain‐reliever‐use‐2013.pdf. Published August 2013. Accessed October 8, 2015.

• Merrill, Joseph. Duncan, Mark. Addiction Disorders. Med Clin N Am. 98 (2014) 1097‐1122.

• Berna C, et al. Mayo Clin Proc. 2015• Coffin, P. et al. Non randomized Intervention Study of naloxone Coprescription for Primary Care Patients Receving Long Term Opioid Therapy for Pain. Annals of Internal Medicine. Vol 165. No 4. August 2016. p245‐252

48

17

References

• Oliva, E. Gordon, A. Barriers to use of Pharmacotherapy for Addiction Disorders and How to Overcome Them. Current Psychiatry. July, 2011. 13:374‐381.

• DeWitt, P. et al. CNS Drugs. 2005. 19:517‐537

• Costen, T. George, T. The Neurobiology of Opiate Dependence: Implications for Treatment. Sci Pract Perspect. July, 2002. 1(1): 13‐20.

• Fishbain, D. Rossamoff, H. Cutler, R. Rossamoff, R. Opiate Detoxification Protocols: A Clinical Manual. Annals of Clinical Psychiatry. Vol 5. 1993. Issue 1. Published online Dec 2011.

• Fullerton, CA. Kim, M. Thomas, CP. Et al. Medication‐assisted treatment with Methadone: assessing the evidence. Psychiatric Services. 2014;65(2): 146‐57.

• Kessler, R. Psychiatric Epidemiology: selected recent advances and future directions. Bulletin of the WHO. 2000. 78(4). 464‐474.

• Walker, Tracey. Program Drops Opioid Dispensing 50%. Managed Healthcare Executive. December, 2017. P37

49

1

Non‐Insulin Therapy for Type 2 Diabetes

Basem Mishriky

Clinical Assistant Professor

East Carolina University

Greenville, NC

Disclosure

• No conflict of interest

• Residency: Internal Medicine at East Carolina University

• Fellowship: Diabetes fellowship at East Carolina University

Objectives

• Discuss the rationale of non‐insulin therapy

• Review and compare two common diabetes guidelines

• Explore the different approaches for common clinical scenarios

• Review when and how to initiate newer classes

2

Insulin Resistance

• Insulin resistance in muscle and liver associated with relative β‐cell failure(collectively called “Triumvirate”) represent the core pathophysiologic defects in type 2 diabetes [1].

• The United Kingdom Prospective Diabetes Study (UKPDS 33) [2] concluded that intensive blood‐glucose control by either sulfonylurea or insulin substantially decreased the risk of microvascular complications but not macro‐vascular disease in patients with type 2 diabetes.

That is why this lecture is important!!

[1] Diabetes 2009; 58: 773. [2] Lancet 1998; 352: 837.

American Diabetes Association Dia Care 2017;40:S64-S74

©2017 by American Diabetes Association

ADA Guideline 2017


©2018 by American Diabetes Association

ADA Guideline 2018

3

Endocrine Practice 2018; 24: 91

Case 1

• A 45‐year‐old Male with no significant past medical history who is presenting to clinic today for an annual physical exam.

• Physical exam shows acanthosis nigricans and multiple skin tags.

• Hemoglobin A1c is 8.5% (repeat is 8.4%).

• Patient is not on any medication for his diabetes.

What is the most appropriate next step in management?

ADA guideline AACE/ACE guideline

Management of newly‐diagnosed type 2 diabetes

Hemoglobin A1c is less than 9%

One agent

Preferably Metformin


Hemoglobin A1c is more than or equal 7.5%

Two agents

Metformin AND preferably GLP‐1 RA


4

Case 2

• A 45‐year‐old Female who has a history of recently diagnosed type 2 diabetes who is presenting to clinic for follow up.

• Hemoglobin A1c is 8.0% (3‐months ago was 8.5%).

• Patient is on maximally tolerated dose of metformin extended release.



Add‐on therapy to metformin

Diabetes is uncontrolled

On maximally tolerated metformin

Does the patient have ASCVD?

No Add an agent from the six preferred groups




Add an agent as suggested by the hierarchy order

Preferably add GLP‐1 RA then SGLT‐2i


Case 3

• A 46‐year‐old Female with history of type 2 diabetes, coronary artery disease, hypertension, dyslipidemia, and obesity.

• Her hemoglobin A1c 3 months ago was 7.5% but today is 7.8%.

• Patient is on maximally tolerated dose of metformin.

Is this patient different from the previous case?


5


Add‐on therapy to metformin



Does the patient have ASCVD?

Yes Consider adding an agent with proven cardiovascular benefit




Add an agent as suggested by the hierarchy order

Preferably add GLP‐1 RA or SGLT‐2i


Cardiovascular safety studies for GLP‐1 RATrial (# of participants)

Groups (median fu)

Characteristics MACE outcome CV mortality All‐cause mortality hHF Occurrence of MI or stroke

LEADER(9340)[1]

Liraglutidevs placebo(3.8 years)

High risk for cardiovascular disease (81.3% had CV disease)

Lira: 608/4668 (13%)Plac: 694/4672 (14.9%)HR 0.87 (0.78 – 0.97)

Lira: 219 (4.7%)Plac: 278 (6%)HR 0.78 (0.66 – 0.93)

Lira: 381 (8.2%)Plac: 477 (9.6%)HR 0.85 (0.74‐0.97)

Lira: 218 (4.7%)Plac: 248 (5.3%)HR 0.87 (0.73‐1.05)

No differences were not significant

SUSTAIN‐6(3297)[2]

Semaglutidevs placebo(2.1 years)

High risk for cardiovascular disease (83% had CV disease)

Sema: 108/1648 (6.6%)Plac: 146/1649 (8.9%)HR 0.74 (0.58 – 0.95)

Sema: 44 (2.7%)Plac: 46 (2.8%)HR 0.98 (0.65 – 1.48)

Sema: 62 (3.8%)Plac: 60 (3.6)HR 1.05 (0.74‐1.5)

Sema: 59 (3.6)Placebo: 54 (3.3)HR 1.11 (0.77‐1.61)

Significantlylower incidence for non‐fatal stroke

EXSCEL(14,752)[3]

Exenatidevs placebo(3.2 years)

With or without cardiovasculardisease (73.1% had CV disease)

Exen: 839/7356 (11.4%)Plac: 905/7396 (12.2%)HR 0.91 (0.83 – 1.00)

Exen: 340 (4.6%)Plac: 383 (5.2%)HR 0.88 (0.76 – 1.02)

Exen: 507 (6.9%)Plac: 584 (7.9%)HR 0.86 (0.77‐0.97)

Exen: 219 (3.0%)Plac: 231 (3.1%)HR 0.94 (0.78‐1.13)


ELIXA(6068)[4]

Lixisenatidevs placebo(25 months)

Had acute coronary event within 180 days before screening

Lixi: 406/3034 (13.4%)Plac: 399/3034 (13.2%)HR 1.02 (0.89 – 1.17)

Lixi: 156 (5.1%)Plac: 158 (5.2%)HR 0.98 (0.78 – 1.22)

Lixi: 211 (7.0%)Plac: 223 (7.4%)HR 0.94 (0.78‐1.13)

Lixi: 122 (4.0%)Plac: 127 (4.2%)HR 0.96 (0.75‐1.23)


[1] NEJM 2016; 375: 311. [2] NEJM 2016; 375: 1834. [3] NEJM 2017; 377: 1228. [4] NEJM 2015; 373: 2247.

Cardiovascular safety studies for SGLT‐2i and TZDTrial (# of participants)

Groups(average fu)

Characteristic MACE Outcome CV mortality All‐cause mortality hHF Occurrence of MI or stroke

EMPAREG (7020)[1]

Empagliflozinvs placebo(3.1 years)

Established CV (99%) disease

Empa: 490/4687 (10.5%)Plac: 282/2333 (12.1%)HR 0.86 (0.74‐0.99)

Empa: 172 (3.7%)Plac: 137 (5.9%)HR 0.62 (0.49 – 0.77)

Empa: 269 (5.7%)Plac: 194 (8.3%)HR 0.68 (0.57‐0.82)

Empa: 126 (2.7%)Plac: 95 (4.1%)HR 0.65 (0.5‐0.85)

No significant differencebetween groups

CANVASCANVAS‐R(10,142)[2]

Canagliflozinvs placebo(188.2 weeks)

High CV risk (65% had CV disease)

HR 0.86 (0.75 – 0.97) HR 0.87 (0.72 – 1.06) HR 0.87 (0.74‐1.01) HR 0.67 (0.52‐0.87)

No significant differencebetween groups

PROactive(5238)[3, 4]

Pioglitazone vs placebo(34.5 months)

Extensive macro‐vasculardisease

Pio: 257/2605 (9.9%)Plac: 313/2633 (11.9%)HR 0.82 (0.70‐0.97)

Pio: 127 (4.9%)Plac: 136 (5.2%)HR 0.94 (0.74‐1.20)

Pio: 177 (6.8%)Plac: 186 (7.1%)HR 0.96 (0.78‐1.18)

Pio: 149 (6%)Plac: 108 (4%)p=0.007

Pio reduced the risk of recurrent stroke [5] and recurrent MI [6].

[1] NEJM 2015; 373: 2117. [2] NEJM 2017; 377: 644. [3] Lancet 2005; 366: 1279. [4] Am Heart J 2008; 155: 712. [5] Stroke 2007; 38: 865. [6] J Am CollCardiol 2007; 49: 1772.

6

Bonus question

Intensification of diabetes medications was investigated in a retrospective analysis published in 2011 involving 12,566 patients with type 2 diabetes who were uncontrolled on metformin monotherapy.

According to this article, how long did it take to intensify treatment in uncontrolled patients?

• 3‐6 months

• 9‐12 months

• 14 months

• 16 months

[1] Diabetes Obes Metab 2011; 13: 765.

When and how to initiate Metformin

Initiation of metformin [1]:

• Start metformin 500 mg once or twice daily with meals for 1 week

• After a week, if no GI side effects, increase metformin to 1000 mg twice daily

• If GI side effects appear as doses advanced, decrease to previous lower dose.

• My way One pill of the metformin 500 mg XR once weekly to a maximum dose of 1000 mg twice daily or to a maximally tolerated dose without GI side effects

[1] Diabetes Care 2009; 32: 193

When and how to initiate GLP‐1 RA

[1] Diabetes Care 2018; 41 (suppl 1): S73. [2] Endocrine Practice 2018; 24: 91

GLP‐1 RA

Reasons to consider this group

• Reduction of hemoglobin A1c (high potency)• No hypoglycemia (except if added to SU/insulin)• Weight loss• Cardiovascular benefit (particularly with Liraglutide and Semaglutide)• Some are once weekly (Dulaglutide, Exenatide ER, and Semaglutide)

Drug‐specific and patient factors to consider

• GI side effects (Nausea, vomiting, and diarrhea)• ? Pancreatitis• Avoid in patients with personal or family history of medullary thyroid carcinoma or multiple neoplasia syndrome type 2 (MEN 2)• Injectable and expensive

Compounds • Liraglutide: Start 0.6 mg once daily for 1 week increase to 1.2 mg daily• If remains uncontrolled, may increase to 1.8 mg once daily.• No renal or hepatic dose adjustment. There is limited data in renal patients.

• Semaglutide: Start 0.25 mg once weekly for 4 weeks to be increased to 0.5 mg once weekly.• If remains uncontrolled, may increase to 1 mg once weekly.

• Exenatide extended release: 2 mg once weekly• CrCl <30 mL/min or ESRD: Not recommended

• Dulaglutide: Start 0.75 mg once weekly. • If remains uncontrolled, may increase to 1.5 mg once weekly.• No renal adjustment

• Exenatide twice daily: Start 5 mcg twice daily within 60 minutes prior to meals. May increase to 10 mcg after one month.• Lixisenatide: Start 10 mcg qd for 14 days then increase to 20 mcg qd.

• GFR <15 mL/minute/1.73 m²: Not recommended.

7

When and how to initiate SGLT‐2i

[1] Diabetes Care 2018; 41 (suppl 1): S73. [2] Endocrine Practice 2018; 24: 91

SGLT‐2i

Reasons to consider this group

• Reduction of hemoglobin A1c (intermediate potency)• No hypoglycemia (except if added to SU/insulin)• Weight loss• Cardiovascular benefit (empagliflozin and canagliflozin)

Drug‐specific and patient factors to consider

• Dehydration and orthostatic hypotension• Genital infections• Increased bone fracture• Risk for amputation with canagliflozin• Less common: euglycemic DKA and urosepsis• Relatively expensive

Compound (s) • Empagliflozin: Start 10 mg once daily. May increase to 25 mg once daily• GFR <45 mL/min/1.73 m²: Use is not recommended

• Canagliflozin: Start 100 mg once daily before first meal. May increase to 300 mg once daily• GFR 45‐59 mL/min/1.73 m²: Maximum dose is 100 mg once daily• GFR <45 mL/min/1.73 m²: Use is not recommended

• Dapagliflozin: Starting 5 mg once daily. May increase to 10 mg once daily• GFR <60 mL/min/1.73 m²: Use is not recommended

• Ertugliflozin: Starting 5 mg once daily. May increase to 15 mg once daily• GFR <60 mL/min/1.73 m²: Use is not recommended

Case 4

• A 46‐year‐old man who has no previous past medical history who is seen in clinic today for a routine physical. He is asymptomatic.

• His hemoglobin A1c checked today in clinic is 11% (repeat is 11.1%).



Therapy for hemoglobin A1c >9%

A1c is greater than or equal 10%, blood glucose is greater than or equal 300 mg/dL, or patient is

markedly symptomatic

Consider combination injectable therapy


A1c is greater than 9%

Is the patient symptomatic?

NoMay consider dual or triple non‐insulin therapy


8

Case 5

• A 45‐years‐old Male with history of type 2 diabetes, hypertension, dyslipidemia, and coronary artery disease.

• He is taking metformin XR 500 mg as two pills twice daily, insulin glargine 120 units daily, and insulin aspart 40 units three times daily before meals.

• Weight is 100 kg. Insulin/weight is 2.4 units/kg.

• Hemoglobin A1c is 10%.

What is the next step in management?

ADA guideline

Add‐on therapy to insulin

Suboptimal glycemic control requiring large insulin doses

Adjunctive use of TZD or SGLT‐2i may help to improve control and reduce the amount of insulin

needed


Summary

• When metformin fails, we need to evaluate ASCVD risk and consider agents with established data to reduce cardiovascular disease.

• Drugs with proven CV benefits are:• Empagliflozin and canagliflozin

• Liraglutide and semaglutide (exenatide ER had a trend but were not significant)

• Pioglitazone (however, caution while using given heart failure)

• Non‐insulin agents can be considered even with severely uncontrolled diabetes (ie hemoglobin A1c >9%).

• Non‐insulin agents can be added at almost all stages of the disease even while on insulin.

9

Questions?• A Quote from Egypt

A difference of opinion does not spoil relations

• A Quote by Aristotle

The more you know, the more you know you don’t know

2018 ANNUAL SCIENTIFIC SESSION Saturday Handouts€¦ · 2018 ANNUAL SCIENTIFIC SESSION Saturday...

Documents

Transcript of 2018 ANNUAL SCIENTIFIC SESSION Saturday Handouts€¦ · 2018 ANNUAL SCIENTIFIC SESSION Saturday...