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Medical recordB E R K S C O U N T Y M E D I C A L S O C I E T Y

Your Community Resource for What’s Happening in Healthcare

WORKINGTOGETHER

Jason T. Bundy, MDChronic Pain Management

William Santoro, MDAddiction Medicine Specialist

READING HEALTH PHYSICIAN NETWORK

Cardiology Associates of West Reading is now Reading Health Physician Network Cardiology.

Mussaber Ahmad, DOMichael Avedissian, MD Olivera Chandler, MD Eric Elgin, MD Adam Feldman, MDWilliam Finneran, III, MD Jared Green, DO Earl Hope, MD Michael Koslow, MD Anthony Licata, MD Agnieszka Mochon, MD Matthew Nolan, MD David Scollan, MD, PhD John Serrian Jr., MD Peter Will, MD Gregory Wilson, DO

The same doctors you trust, the same exceptional care you expect. Now, all part of our comprehensive multi-specialty Reading Health Physician Network for the coordinated care you want and the value you deserve.

Together, our leading physicians provide seamless access to award-winning cardiac care you count on.

For more information, visit ReadingHealthCardiology.org or to schedule an appointment, call 610-375-6565.

It’s not a change of heart.Just a change of name.

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A Quarterly Publication

To provide news and opinion to support professional growth and personal connections within

the Berks County Medical Society community.

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Berks County Medical Society BECOME A MEMBER TODAY!

Go to our website at www.berkscms.org

and click on “Join Now”

Content Submission: Medical Record magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Berks County Medical Society. Submissions can be photo(s), opinion piece or article. Typed manuscripts should be submitted as Word documents (8.5 x 11) and photos should be high resolution (300dpi at 100% size used in publication). Email your submission to info@berkscms.org for review by the Editorial Board. Thank YOU!

Medical Record magazine is published by Hoffmann Publishing Group, Inc. 2921 Windmill Road, Reading, PA 19608 | HoffmannPublishing.com | 610.685.0914

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Medical recordB E R K S C O U N T Y M E D I C A L S O C I E T Y

ContentsBerks County Medical Society

MEDICAL RECORD

Lucy J. Cairns, MD

Editorial Board D. Michael Baxter, MD

Daniel B. Kimball, MD, FACP Betsy Ostermiller

Berks County Medical Society Officers Andrew R. Waxler, MD

PresidentGregory T. Wilson, DO,

President ElectD. Michael Baxter, MD Chair, Executive Council

Michael Haas, MD Treasurer & Chair, Finance Committee

Anne Rohrbach, MD Secretary

Lucy J. Cairns, MD Immediate Past President T. J. Huckleberry, MPA

Executive DirectorBetsy Ostermiller Executive Assistant

Berks County Medical Society875 Berkshire Boulevard, Suite 102B, Wyomissing, PA 19610

Phone: 610.375.6555 | Fax: 610.375.6535 Email: info@berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society.

Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication.

The Berks County Medical Record (ISSN #0736-7333) is published four times a year by the Berks County Medical Society, 875 Berkshire Boulevard, Suite 102B, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 875 Berkshire Boulevard, Suite 102B, Wyomissing, PA 19610.

READING HEALTH PHYSICIAN NETWORK

Cardiology Associates of West Reading is now Reading Health Physician Network Cardiology.

Mussaber Ahmad, DOMichael Avedissian, MD Olivera Chandler, MD Eric Elgin, MD Adam Feldman, MDWilliam Finneran, III, MD Jared Green, DO Earl Hope, MD Michael Koslow, MD Anthony Licata, MD Agnieszka Mochon, MD Matthew Nolan, MD David Scollan, MD, PhD John Serrian Jr., MD Peter Will, MD Gregory Wilson, DO

The same doctors you trust, the same exceptional care you expect. Now, all part of our comprehensive multi-specialty Reading Health Physician Network for the coordinated care you want and the value you deserve.

Together, our leading physicians provide seamless access to award-winning cardiac care you count on.

For more information, visit ReadingHealthCardiology.org or to schedule an appointment, call 610-375-6565.

It’s not a change of heart.Just a change of name.

RH16-04 BerksCountyMedRecord_Announcement ad_8.375x10.875_2Q2016_FINAL.indd 1 3/24/16 4:07 PM

22 Abstinence Programs

24 Oral Health Update

26 Tracking the Tracker: The Long Road for PA’s Prescription Drug Monitoring Program

30 To be, or not to be - the role of the county medical society

36 HR Insights: 5 Important HR Issues to Monitor for 2016

4 Editor’s Comments

6 President’s Message

8 Compass Points

32 Foundation Update

39 Alliance Update

Features

in every issue

THE TREATMENT of Addiction

10

16

Chronic Pain MANAGEMENT

ed i t o r’s co m m e n t s

The jury is in. Physicians (and other prescribers) have been and may still be guilty of writing too many prescriptions for opioid pain medications, often supplying more pills and at a higher dose than is necessary or prudent, prescribing without first

trying less risky alternatives, prescribing without carefully assessing the patient for abuse risk factors, without effectively educating the patient about the risk of addiction, and without always knowing if the patient has other pills in his or her medicine cabinet that could be dangerous when taken with opioids. Adding to the problem is the fact that regulators and law enforcement cannot always identify and shut down “pill mill” practices promptly. We have all seen the shocking statistics such as:

• 259 million prescriptions for painkillers were written in the U.S. in 2012—enough for every adult to have a month’s supply.

• As the quantity of prescription painkillers dispensed quadrupled between 1999 and 2013, so did the number of deaths attributed to these medications, and by 2010 there were close to half a million emergency department visits related to opioid use, and opioid use killed more Americans than auto accidents.

• In 2014, 10.3 million people reported using prescription opioids for non-medical purposes, an estimated 1.9 million people had an opioid use disorder related to prescription pain relievers, and an estimated 586,000 had an opioid use disorder related to heroin. (SAMSHA’s 2014 National Survey on Drug Use and Health)

Closely paralleling the increase in prescription opioid

dispensing has been an increase in heroin use in the U.S., and some have suggested that the early success of recent efforts to reduce

use of prescription opioids may be further fueling the heroin epidemic by causing some opioid-dependent people to turn to illicit drugs. However, a

review article in the January 14, 2016 New England Journal of Medicine1 included data indicating that fewer than 5% of non-medical users of prescription opioids go on to use heroin, and identified a number of other factors (such as increased availability of heroin that is more potent and less costly than in the past) as probably more important in driving the rise in heroin use. Still, with so many prescriptions being written, even a small percentage of patients transitioning to heroin use is a significant problem. So, yes! —physicians—along with other health professionals, pharmaceutical companies, legislators, and law enforcement--must continue efforts to swing the pendulum of opioid use and abuse back the other way. But, as pointed out by Gus Geraci, M.D., in his Pennsylvania Physician column re-printed in the Winter edition of the Medical Record, we should be taking

Lucy J. Cairns, MD Editor

“YES, but...”

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great care that the pendulum does not swing so far back that people who benefit from opioids suffer needlessly. The number of Americans who report long-term pain is huge—approximately 100 milllion (or about one-third of the population), and their voices need to be heard in this conversation. Results from the 2012 National Health Interview Study show that about 25.3 million adults had pain every day in the previous 3 months, and nearly 40 million reported severe pain at some point. These figures represent a reservoir of suffering that should concern us just as much as the statistics on drug abuse. Some of the responses to the opioid crisis would not be expected to have any deleterious effect on the ability of physicians to treat pain effectively. These responses include the introduction of abuse-resistant formulations of prescription opioids, drug take-back programs for left-over medication, improved education of medical students and resident physicians, CME for practicing physicians, and prescription drug monitoring programs such as the controlled substances database physicians in Pennsylvania should have access to before the end of the year. Other responses, especially those by legislative and regulatory bodies, threaten to create barriers to providing appropriate pain relief to patients who do benefit from opioids. In Massachusetts, the STEP law (The Act Relative to Substance Use Treatment, Education, and Prevention) which became effective March 14, 2016 puts a 7-day limit on the first opiate prescription a physician issues to a patient and requires the prescriber to check the Prescription Monitoring Program database before writing every prescription for a Schedule II or Schedule III controlled substance. However, there are provisions for some exceptions to these limitations, and the law includes additional provisions designed to reduce opioid abuse, expand insurance coverage for substance abuse treatment, and increase funding for addiction services. A summary can be found on the website of the Massachusetts Medical Society, which supported this legislation. Many other states have enacted or plan to enact legislation designed to reduce opiate prescribing. On Febuary 5, 2016 the Reading Eagle reported that three Pennsylvania state senators plan to propose legislation placing a 7-day limit on opiate prescriptions that could be written by emergency care physicians. On the national stage, on March 16 the CDC issued a new guideline for primary care clinicians treating chronic non-cancer pain in adults. Included in the guideline are some specific dosage and time

1 Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. Wilson M. Comptom, M.D., M.P.E., Christopher M. Jones, Pharm. D., M.P.H., and Grant T. Baldwin, PhD., M.P.H. N Engl J Med 2016; 374: 154-163.2 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – Unites States, 2016. MMWR Recomm Rep 2016; 65:1-49. DOI: http://dx.doi.org/10. 15585/mmwr.rr6501e1er. 3 http://www.painmedicinenews.com/Review-Articles/Article/02-16/Draft-CDC-Opioid-Guideline-Pain-Medicine-Experts-Discuss/35197/ses=ogst

limitations for the use of opioids in this population. A trial of non-pharmacologic treatment and non-opioid pharmacologic treatment before prescribing an opioid is recommended. Also recommended for most patients is a multimodal approach (pharmacologic plus treatments such as Cognitive Behavioral Therapy, physical therapy, acupuncture, weight loss, spinal manipulation, yoga, and massage therapy). This last recommendation is followed by this acknowledgement: “Multimodal therapies are not always available or reimbursed by insurance and can be time-consuming and costly for patients.”2 Dr. Jason Bundy sent me this link3 to a discussion of the CDC guideline by several pain experts. Among the comments offered by Lynn R. Webster, MD (Past President, American Academy of Pain Medicine) were: “The prespecified doses and time limits are going to be inadequate for many people, particularly for those who have been on higher doses. There is low to very low [quality] evidence for the dose limits suggested in the guideline. … The genetic variability in response to each opioid, along with differences in clinical needs, mandate an acceptable range much higher than that stated in the guideline.” Bob Twillman, Ph.D. (Executive Director, American Academy of Pain Management) commented, “We absolutely need to get policymakers to understand that opioids are used to such a great extent because they are often an easily accessed treatment option. If we want to reduce the inappropriate use and overuse of opioids, then we need to be able to ensure that our patients have unfettered access to other kinds of treatments that work for persistent pain.” Although the guideline does not have the force of law, it may be used by payors to limit insurance coverage for opioid medications and will almost certainly be used by plaintiff’s attorneys, so physicians will need to think very carefully before deviating from it. If Pennsylvania legislators do craft legislation designed to limit opioid prescribing, I hope and trust they will think very carefully about possible unintended consequences for the many state residents who suffer from pain and listen to their voices.

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Andrew Waxler, MD, FACC President

Pr e s i d e n t’s me s s a g e

It seems as though wherever you turn, the media is reporting on the opioid crisis in the U.S. and, sadly, Berks County is home to one

of the worst epidemics in the country. Over the past two decades, several factors have conspired to create “the perfect storm” leading to this growing problem of both addiction and overdose related to painkillers (particularly opioids). The leadership of our Berks County Medical Society has formed a Substance Abuse Task Force to address the crisis, identify the factors that have led us to this point, and try to make an impact here in Berks County. While there is no immediate cure, we believe that the education of our local doctors as well as our community members is the first step in tackling this devastating problem. The task force has organized two important events: 1.) a “drug take-back” event for the general public on April 30, and 2.) an evening CME program on May 10th. These will be the first of several programs designed to address the issue of opioid addiction and overuse – both with health care providers as well as the general public. The drug “take-back” event will take place at the Reading Fightin’ Phils stadium on Saturday, April 30th and will be highly advertised to the public. The event will hopefully educate the general public on the dangers associated with the misuse of opioid medications as well as the importance of disposing of them properly (rather

than either flushing them into the water system or leaving unused pills in the medicine cabinet for others to find). We, as the Medical Society, want to make a difference right here in our backyard, and we feel that this event could have a big impact. The May 10 CME program, at the Doubletree Hotel, will include some highly regarded guest speakers who will discuss the scope of the problem, current treatment strategies, and the impact on health care in the future. We are honored to have Dr. Rachel Levine, the Pennsylvania Physician General, and Gary Tennis, the Pennsylvania Secretary of Drug & Alcohol Programs, as our Keynote Speakers; furthermore, a panel of local experts will discuss various Berks County issues and review several case studies. Registration is easily done through our website: berkscms.org. Our goals for this CME program include educating healthcare providers, creating a collaborative approach to patient care within our local healthcare institutions, and providing a value/benefit to our membership. Of course, these events could not occur without sponsorship. We are most grateful to Reading Health System, Penn State St. Joseph, the Caron Foundation, New Directions Treatment Services, Boscov’s, the Reading Fightin’ Phils, and BCMS Past President Jerome Marcus, M.D., for their generous support.

Please consider joining us for both of these important programs:April 30th to get out and help the public,

and May 10th for an evening of collaboration, education,collegiality and those all-important Safety CME credits!

As fellow clinicians—

Now, one call is all you need to get into the Penn State Hershey system via MD Network:

1-800-233-4082 (WANT TO CONNECT TO PEDIATRIC PROVIDERS? SIMPLY PRESS ‘4’ FOR KIDS TO BE CONNECTED

TO PENN STATE HERSHEY CHILDREN’S HOSPITAL.)

For the Berks County families you serve

what inspires you, inspires us.

For more information, please visit the MD Network web page at PennStateHershey.org/mdnetwork.

MD Network is reserved for clinicians and office support staff only.

U.Ed. MED 16-8459 MC

Penn State Hershey’s MD Network serves as a resource to referring providers at any stage of the referral relationship.

April 30

MAY 10CME

As fellow clinicians—

Now, one call is all you need to get into the Penn State Hershey system via MD Network:

1-800-233-4082 (WANT TO CONNECT TO PEDIATRIC PROVIDERS? SIMPLY PRESS ‘4’ FOR KIDS TO BE CONNECTED

TO PENN STATE HERSHEY CHILDREN’S HOSPITAL.)

For the Berks County families you serve

what inspires you, inspires us.

For more information, please visit the MD Network web page at PennStateHershey.org/mdnetwork.

MD Network is reserved for clinicians and office support staff only.

U.Ed. MED 16-8459 MC

Penn State Hershey’s MD Network serves as a resource to referring providers at any stage of the referral relationship.

8 | w w w . b e r k s c m s . o r g

Timothy J. (T.J.) Huckleberry, MPA Executive Director

co m Pa s s Po i n t s

As many of you already know BCMS has decided to move from our office in the Berks Visiting Nurses Office Building to 875 Berkshire Boulevard, Suite 102B. We will officially be operational on April 1. Once again on behalf of the Medical Society we

thank BVNA for housing us for so many years and I look forward to partnering with them in our future initiatives. In the meantime, Betsy and I are hard at work packing, purging, and prepping for our move. Being the new guy this move once again gave me another opportunity to review our files and other accumulated documents to get a better sense of who we were and what we can build on. I was particularly interested in our fabled BCMS hutch. For members who are unaware, our hutch houses some of our Society’s most historic artifacts and documents. It holds rare medical books donated throughout our 192-year history, antique medical equipment, minutes of meetings and rosters of countless past members and councils, and archives of our Medical Record dating back as far as 1918. It’s our most tangible link to our Society’s great lineage. As I kept diving into the seemingly endless amounts of cabinet space I was half expecting to find Benjamin Rush’s last will and testament or some etching in the back walls illustrating a caveman doctor’s first attempt at collecting an insurance claim ( I imagine a big spikey club was involved). I was sure I was going to uncover something special as I continued my “excavation” ...and I did. Neatly standing in the lowest and last cabinet I cleaned out was an old heavy cardboard poster tube with a 15 cent stamp and a South Chicago return address. Its contents was a perfectly intact and incredibly illustrated membership certificate with the enrollment date of 1896. The name on the certificate was Dr. Albert Rhoads, M.D. It reads:

After reading this, I hope you too feel how remarkable and enduring these words are and how eerily similar our values and goals are to that of our forerunners. It certainly gave me some thought. I imagine what Dr. Rhoads would think of medicine today, with all of our advancements and technology and yet all of the hurdles that physicians have to undergo to simply practice;

for your Membership Dr. Albert Rhoads

THANK YOU

Instituted for the promotion of Medical Knowledge for the mutual improvement and social intercourse of Medical Practitioners, and for supporting the character of the Medical

Profession; reposing confidence in the knowledge, skill, and integrity of

Dr. Albert Rhoads, M.D. have constituted him as an active member thereof.

Elected July A.D. 1883In the testimony where of are hereby affixed the names of the proper officers

this 14th day of January A.D. 1896.

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Berks Visiting Nurses Association!

On behalf of all of our members and staff we would like to thank you for the many years of partnership between our organizations. We

truly enjoyed our time being under your roof and we look forward to many more years of

serving our community together.Best of Luck,

T.J. Huckleberry, BCMS Exec. Director

how his horse and carriage was his version of telehealth, and how lucky he must feel that all he had to do was focus on patients and his practice. Or in the case of BCMS, how proud he must feel that such a prominent part of his profession has endured. I then think forward to you, our member physicians, that despite living in a time where everything is at a break neck pace and every patient comes equipped with a mile of red tape and a dollar sign, you all still choose to make an impact on your community by electing to join our Society. And just how Berks County needed Dr. Rhoads then, our community needs you now. Our opioid abuse crisis is not going away. Neither are our skyrocketing prescription drug prices. Also, I would venture to say that treating your patients the way you would prefer is only getting more difficult. There is a great and often used quote from the movie Gladiator; “what we do here, echoes an eternity”; 120 years ago Dr. Rhoades realized that the best way to serve completely as a physician and leader of the community was to join the Berks County Medical Society and with his membership he helped build our society’s legacy. Even 100 years after his passing there is a piece of him still woven in our current medical society. I encourage all physicians, members and non-members, to take a hard look at what BCMS and PAMed are doing for you today, to get involved, and to leave your mark. I invite all of our members to stop into our new office after April 1 (875 Berkshire Blvd, Ste 102B, Wyomissing, PA 19610) and take a look at all of our history and to see our newly framed and prominently placed Certificate of Membership for Dr. Rhoads. And on behalf of the Berks County Medical Society, as Executive Director, I once again thank Dr. Albert Rhoads for his on-going membership.

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The word “addict” no longer has a place in the

English language. I know that many people will use that term as a badge of honor. But the word is most often used as a derogatory comment and, therefore, it is still not an appropriate word. To say someone is an “addict” is to say that person IS the disease as opposed to someone HAVING a disease. When attempting to open a drug and alcohol treatment facility I have heard more than once a community member say, “We don’t want you bringing those ‘addicts’ into our neighborhood.” It is a much more powerful statement than, “We don’t want you bringing people addicted to drugs into our neighborhood.” We all need to think about the words we use and why we use them. We not only need to stop using the word, we need to stop believing the concept of the word. To quote the famous American philosopher and physician William James, “A great many people think they are thinking when they are merely rearranging their prejudices.”— William Santoro, M.D.

The treatment of addiction, like every other field of medicine, is (and should be) in a constant state of evolution. First some definitions: opiates are naturally occurring alkaloids derived

from the opium poppy. Examples of opiates are heroin, morphine and codeine. Opioids are synthetic or partially synthetic drugs that are manufactured to work in a similar way to opiates. Examples of opioids are methadone, oxycodone and hydrocodone. Today the two terms, opiates and opioids, are often used interchangeably. The face of opiate addiction has changed over history. Opiates were used in the Civil War to treat pain from injuries received on the battlefield. From the Civil War until recently society has looked upon people addicted to opiates as people with a moral failure rather than a disease. The Harrison Narcotic Act of 1914 effectively moved addiction to opiates from the medical field to the legal arena when it made it illegal for a physician to treat a patient addicted to opiates with another opiate. Opiate/Opioid use disorder is an illness that affects the social, legal and medical fabric of life and may sometimes result in death. With no effective medical treatment of this illness, the only treatments to flourish were non-medical. Narcotics Anonymous was founded in 1948 and is based on the 12-step program of Alcoholics Anonymous. While Narcotics Anonymous and other non-medical based treatments have been effective for some, the vast majority of patients addicted to opiates relapses back to their drug of choice and begin on a revolving door of “use-treatment-short term sobriety-relapse.” While independent studies have shown a drop-out rate as high as 90%, some well-intentioned programs continue to preach a program of sobriety based on a system that has worked for the members within the program and quote statistics such as having 80 to 100% success rates if the patients follow their program.

THE TREATMENT

Me d i c a l Re c o R d Fe at u R e

of Addiction by William Santoro, MD

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THE TREATMENT

The catch being those who relapse do not count as a failure of the program, but rather a failure of not following the program. Relapse prevention is a crucial component of effective treatment. Recovery has biological (medical), psychological, sociological and spiritual components that need to be addressed to achieve a full and functioning life. As healthcare providers we have an obligation to positively impact patients’ lives affected by substance use disorder.

HISTORY OF METHADONE

German scientists seeking a new analgesic that was less addicting than morphine created methadone during World War II. Methadone is a synthetic opiate and acts as a mu-opioid receptor agonist. Methadone attaches to the receptor and activates it in the same way as every other opiate. However, methadone’s gradual onset and long half-life limits the euphoric effects. Research by Dole, Nyswander and Kreek in the late 1960s showed its efficacy for opiate addiction. The original studies were done utilizing a blocking dose: a dose that, if other opiates were used, would block the euphoric effect of the illicit drugs. In 1971 the federal government set up regulations, and methadone clinics began treating opiate dependent patients. Methadone maintenance programs have been shown to be the most effective means for treating heroin addiction. The term maintenance is used because the goal is to maintain the patient on methadone to help the patient avoid the negative and often severe effects of opiate withdrawal. Methadone maintenance treatment views opiate addiction as a disease rather than a psychological disorder or character fault. Numerous studies have looked at methadone maintenance programs and a majority of them have concluded that methadone maintenance reduces narcotic-related deaths, crime, the spread of STDs (including HIV and Hepatitis-C) and helps patients gain control of their lives. Although methadone is intended to treat opiate addiction, it is also an extremely physically addictive drug. If not properly adjusted by experienced physicians, it can be dangerous and can cause death. When adjusted slowly and properly, the induction of a patient onto methadone maintenance can achieve the desired results of the patient abstaining from opioid use while not causing unacceptable side effects such as “nodding out” (falling asleep at inappropriate times). When tapered slowly and properly, withdrawal of methadone can be accomplished with minimal symptoms. On the other hand, if induction is done too quickly in an attempt to alleviate all cravings of illicit opioids, overdose, “nodding out” and death due to respiratory depression may occur. Correspondingly, if methadone is withdrawn too quickly, or if methadone is stopped abruptly, the methadone withdrawal symptoms can be more severe, and significantly longer, than heroin withdrawal and can cause death. A well-run methadone program should have a medical director board certified in Addiction Medicine. A good program will not only meet—but will consistently exceed—the government’s minimum requirements for counseling and urine testing. The dose of methadone should be carefully titrated for each individual. Although, when starting a methadone maintenance program, patients have to come in every day and be witnessed taking their medication, over time they may earn the privilege of receiving a dose of methadone to take home for the next day. A maximum of 6 “take-homes” in one week can be earned. It should be stressed that “take-homes” are a privilege, not a right or a guarantee.

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1 2 | w w w . b e r k s c m s . o r g

Patients must demonstrate that they are stable on their dose, attend counseling, and can responsibly handle their medication before being given a take-home. Historically, the dose of methadone given to patients had been low, with artificial restrictions in place. When the dose restrictions were eliminated, the success rate of many programs improved. The success rate of a methadone program is generally based on the rate of abstinence for patients enrolled for more than 1 year. A well-run methadone program typically has a success rate of greater than 80%.

HISTORY OF BUPRENORPHINE

No further medical advancement in the field of Medication Assisted Treatment (MAT) became available until 2001. Buprenorphine was first developed in the late 1970s. It is a semi-synthetic opioid and was first developed as an injectable form of pain medication. It was shown to have only moderate pain relieving properties, but later was proven to be an effective treatment for opiate dependence. In 2001 buprenorphine in combination with naloxone, trade name Suboxone, was approved for the treatment of opiate dependence by the passage of the DATA 2000 Act. The first formulation was a sublingual tablet (later a sublingual strip). Buprenorphine is the active pharmaceutical agent. Naloxone is only minimally absorbed when used as directed. Naloxone is a pure opioid antagonist. The purpose of having naloxone in the product is to prevent the patient from using the medication in a manner not

intended. If the product is used in a way other than sublingually, the naloxone will be absorbed and displace all other opioids, including illicit opioids and prescribed buprenorphine, causing severe opioid withdrawal, known as precipitated withdrawal. Buprenorphine has a very strong affinity to the mu-receptors but causes only a modest activation of the receptors. Activating the mu-opioid receptors causes the euphoric effects of an opioid. Furthermore, the half-life of buprenorphine is estimated to be between 24 and 96 hours. At appropriately used doses, buprenorphine has only mild mu-opioid receptor agonist properties, while at higher doses it has kappa-opioid receptor antagonist properties. Antagonizing the kappa-opioid receptors will cause symptoms of withdrawal. These properties, a strong affinity with only a mild activation of the mu-opioid receptors, kappa-opioid receptor antagonism at high doses and a long half-life, allow buprenorphine products to be used once a day to minimize opiate withdrawals without causing any appreciable euphoria. These properties also put a limit on the dosing of the medication. Regardless of how much buprenorphine is available, the mu-opioid receptor will not be activated further, so increasing the dose will not give any increased euphoria. On the other hand, increasing the dose beyond the recommended amount will cause the kappa-opioid receptors to be antagonized, causing symptoms of withdrawal. Having a shorter history and trying to account for individual program differences, it is difficult to assess the success rate of buprenorphine as a treatment. Accepting that many define success based on a combination of retention in treatment and abstinence of

continued from page 11The Treatment of Addiction

S P R I N G 2 0 1 6 | 1 3

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illicit drug use for at least one year, some independent studies place the success rate of buprenorphine between 25 and 50%.

HISTORY OF NALTREXONE

Naltrexone, as an injection called Vivitrol, is the most recent medication to be approved for the treatment of opiate dependence. It was approved as an injection in April 2006 for alcohol use disorder and in October 2010 for opioid use disorder. As an opioid antagonist, naltrexone occupies the mu opioid receptors in the brain, blocking the euphoric effects of opiates for up to 30 days. While Vivitrol blocks the ability of a patient to attain the euphoric effect from opioids, thereby reducing the risk of relapse, residential and outpatient treatment can provide counseling, 12-step programming and lifestyle changes needed to support long-term addiction recovery. Vivitrol helps patients stay engaged in a drug rehabilitation program, hopefully long enough to develop the skills needed for lifelong recovery. Vivitrol is not an opioid and is non-addictive. Vivitrol has no mood- or mind-altering effects. After an IM Vivitrol injection, the naltrexone plasma concentration has a transient initial peak occurring in approximately 2 hours, followed by a second peak approximately two or three days later. Approximately 14 days after the initial injection, the concentration slowly declines, with measurable levels lasting greater than one month. Because each injection of Vivitrol lasts more than one month, it increases the likelihood of treatment compliance. Vivitrol is generally well tolerated with minimal side effects. Vivitrol can, and should, be used

long-term and often is used at the end of an inpatient rehabilitation program. Because it is not an opioid, Vivitrol is often the first step into MAT. This may come from past belief that using a medication to treat a substance use disorder is simply replacing one addiction with another. This is far from true when any MAT is properly used. Because of its short history, the success rate of Vivitrol is still being determined.

DECIDING WHICH TREATMENT

Different treatment programs are appropriate for different patient populations, and of course there is overlap. Naturally, a non-medical based program would be appropriate for patients who have never attempted any treatment before. Patients and providers should consider MAT when a non-medical based program has been shown to be insufficient to keep a patient in sobriety. It is not unreasonable to consider a more potent MAT if a patient is still not able to remain in sobriety using Vivitrol. Buprenorphine and methadone maintenance are replacement treatments for opioid use disorder. Buprenorphine may be used by a physician, after proper training and certification, on patients addicted to opioids who have not been successful using other treatment programs, or even as a first line treatment after a discussion with the patient concerning all the other options available. Well-run buprenorphine programs will incorporate close follow up, random urine drug testing and outpatient counseling

continued on page 15 >

The Treatment of Addiction

C H R O N I C P A I N

A N O N Y M O U SM E E T I N G S

ATREADING HEALTHREHABILITATION

HOSPITAL

READING HEALTH REHABILITATION HOSPITAL 2802 PAPERMILL ROAD, WYOMISSING, PA 19610

CPA is an anonymous fellowship that welcomes anyone who lives with chronic pain or chronic illness. We come together to practice the Twelve Step program of recovery

with simple tools and principles. We offer each other comfort and understanding by sharing our experience, strength and hope.

We will be meeting every Tuesday at 7PM in Room #1. Any questions call Wayne C. at 610-207-3716.

For more information: chronicpainanonymous.org.

S P R I N G 2 0 1 6 | 1 5

References:1. Kuhn, C. Swartzwelder, S. and Wilson, W. (1998). Buzzed; The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy. W.W. Norton and Company: New York, NY.2. Lyman, MD and Potter, G.W. (1998). Drugs in Society: Causes, Concepts and Control. Anderson Publishing: Cincinnati, OH.3. Inciardi, J.A. and Harrison, L.D. (2000). Harm Reduction: National and Interna-tional Perspectives. Sage Publications: Thousand Oaks, CA. 4. National Institute on Drug Abuse. “NIDA Research and SAMHSA Physician Train-ing Combine to Put Care for Opiate Dependence in Hands of Family Doctor”, October 9, 2002. 5. Weiss, MD et. al. Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence. Arch Gen Psychiatry. 2011; 68(12):1238-1246. 6. Minozzi, Amato, Vecchi, Davoli, Kirchmayer, Verster. Published April 13, 2011. http://www.cochrane.org/CD001333/ADDICTN_oral-naltrexone-as-maintenance-treatment-to-prevent-relapse-in-opioid-addicts-who-have-undergone-detoxification7. Vivitrol Package Insert.

along with buprenorphine. The dose and frequency of office visits should be adjusted to the individual’s need. Measures should be in place to minimize the risk of diversion, such as random callbacks for medication counts and urine drug testing. The program should be set up using an interdisciplinary model including the physician, counseling and, where necessary, social services. A patient who has tried unsuccessfully to achieve sobriety using non-medical programs and first-line MAT programs like Vivitrol and buprenorphine should be considered for referral to a methadone maintenance program. Methadone maintenance should always be considered long-term. Most program directors consider long-term to be a minimum of 2 years and possibly lifetime. The federal government very strictly monitors methadone programs and the number of patients permitted into each program. Among other criteria, to be eligible for admission a patient must be 18 years of age and opioid dependent for more than one year. Pregnant women and patients who are HIV positive are accepted even if they do not meet criteria for admission and even if there are no places available.

FINAL WORD

Whether a patient is in a Vivitrol, buprenorphine or methadone program, the treatment is called “medication assisted treatment.” Although methadone programs are the only ones mandated to deliver specific amounts of counseling, other MAT programs need

to understand the value of treatment beyond medication. Likewise, non-medical based treatment programs need to learn to accept MAT programs as partners in the treatment of this disease. MAT and non-medical based treatment programs need to keep in mind that both have the same goals: treating a person with a chronic, relapsing disease in hopes that the person can live a fully functional life. MAT and non-medical based treatment programs will undoubtedly fail if opioid use disorder is treated as an acute disease rather than the chronic relapsing disease that it is. Psychological, social, nutritional and spiritual counseling are important components of every MAT and non-medical treatment program. When treating a patient with any substance use disorder the provider needs to treat the entire patient and even the entire family, not an isolated illness.

Dr. Santoro has been Board Certified in Addiction Medicine since 1989 and Family Medicine since 1985. In 2014 he was named Chief of the Section of Substance Use Disorder in the Reading Health System. He has been the Medical Director of New Directions Treatment Services, a methadone maintenance treatment program, since 1999. He has also been the Medical Director of the Reading Hospital & Medical Center Drug and Alcohol Program since 1989. He runs outpatient treatment programs using buprenorphine and naltrexone.

continued from page 13The Treatment of Addiction

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Dear Dr.:

I had the pleasure of meeting your patient here at Center for Pain Control today. As you recall, she is a pleasant 55-year-old female with a multiyear history of ongoing back and lower extremity pain. She was actually seen by my practice partner in 2012 who documented your patient underwent an L4-L5 laminectomy and lumbar fusion performed by a local spine surgeon back in 2008. Anyway due to a failed therapeutic relationship with my practice partner, the patient then followed up with another pain specialist who trialed lumbar epidural injections and other options including opioids with some initial relief, but then suboptimal treatment gain longer term. She apparently grew frustrated seeing that physician and now follows back up here to get my take on things. Of note, my practice partner documented the patient has a prior history of illicit drug use and that she is not an optimal candidate to remain on controlled substances. I gather she disagreed. He did offer to consider a lumbar epidural, but she elected to hold off on that. Over the interval years, the patient states she has noticed ongoing back pain and lately the pain has been radiating to her right thigh and leg. In addition she now complains of mid back pain. She fell this summer and underwent CAT scan imaging and these updated images and the old MRI were noted today. Lumbar CAT scan 08/14/2015, “postoperative degenerative change mild-to-moderate stenosis L3-L4. No fracture traumatic subluxation.” Four view lumbar spine 08/14/2015, “L4-L5 postoperative change. Minimal L4-L5 anterolisthesis. Degenerative change similar to prior study.” Lumbar MRI 11/28/2011, “stable lumbar levoscoliosis, stable grade 1 spondylolisthesis L4/L5. Postsurgical change from previous decompressive laminectomy L4-L5 level with placement of bilateral pedicle screws at L4-L5 with a disk spacer. There is mild enhancing epidural fibrosis along lateral margin thecal sac bilaterally right more than left, moderate-to-severe right neural foraminal narrowing is

Me d i c a l Re c o R d Fe at u R e

In the following piece, BCMS member Dr. Jason T. Bundy provides a de-identified case history of a patient with chronic pain. It illustrates many of the complexities, competing priorities, and limitations physicians who treat chronic, non-cancer pain patients often grapple with, and delineates his approach to trying to help such patients while minimizing the risks. For Pain Management specialists such as Dr. Bundy, “threading the needle” is an apt description of the daily challenge of trying to provide the most effective treatment with the least possible risk, under the limitations imposed by patient histories that are not always reliable, lack of access to a prescription drug monitoring system, limited or no insurance coverage for certain treatments, and social and psychological challenges that affect many patients.

— Lucy J. Cairns, MD

CHIEF COMPLAINT:Mid back pain.

1. Mid back pain. 2. 6/10 back right anterior lateral thigh leg pain.

by Jason T. Bundy, MD

Chronic Pain MANAGEMENT

S P R I N G 2 0 1 6 | 1 7

CHIEF COMPLAINT:Mid back pain.

continued on next page >

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noted at the L3-L4 level. This worsened in severity compared to prior exam.”

Indeed today the patient thinks that her prior treating pain management physician trialed a “L3-L4 level” epidural injection with initial relief, but then subsequent injections failed to replicate the good results of the first. She remained on opioids for a period of time, but seems to have good insight that she is not an optimal candidate to be on this or other habit-forming pain medications given her prior history of drug dependency in the past. She follows up with a psychiatrist and states she completely abstains from all illicit or un-prescribed prescription drugs at this point. I gather she was recently given a prescription for Tylenol 3 and Soma and did inquire about a Soma prescription today, but I recommended that we consider alternatives first given the incumbent risks in her particular case. Today in the clinic the patient notes activities like sitting, standing, and walking tend to make her back and right leg pain worse. When her right leg pain is severe, sometimes her right leg feels weak. She denies a recent history of falling relating to it however. Changing position and taking Soma have been relieving factors. She trialed physical therapy within the past year with limited treatment gain and is reasonably compliant with a self-directed exercise program. She continues to take Celebrex and was taking ibuprofen, but reports overall marginal treatment gain with these options.

January 4, 2016Page 2

When questioned how pain affects her life and what agreed upon goals are today, we arrived at reviewing all diagnostic and therapeutic treatment options to both characterize and treat her ongoing back pain so she can avoid relying on habit-forming pain medications.

PMH:1. Anxiety and other psychiatric problems. She follows up with un-recalled psychiatrist locally.2. Notes document a history of ADHD.3. History of illicit drug abuse in the 1980s (crystal meth, marijuana) in this patient who states she is abstaining.

PSH:1. Gastric bypass 2002.2. “Back fusion” 2007 – see HPI.

Current Medications:1. Celebrex, dose not recalled, daily.2. Cymbalta, dose not recalled, daily.

Allergies: Morphine and Fentanyl. She reports hallucinations on OxyContin.

SH: The patient has two children. She has been disabled for years due to her back pain. She smokes one pack of cigarettes per day and smoking cessation was encouraged. She denies a

1. Mid back pain. 2. 6/10 back right anterior lateral thigh leg pain.

1 8 | w w w . b e r k s c m s . o r g

recent history of illicit or prescription drug abuse. She states she abstains completely from alcohol. She admits to a prior history of abuse which she states led to her drug abuse issues in the 1980s.

Review of Systems: Positive for associated weight loss after gastric bypass. She feels depressed. Denies suicidal thoughts. She continues to follow up with her psychiatrist, but she can’t recall his or her name.

PE: General: Alert and oriented x 3, in no acute distress, pleasant. Psychiatric: Mood is okay. Affect appropriate. Vital Signs: Blood pressure is 135/70. Respiratory rate is 18. Heart rates in the low 70s. Cardiovascular: Regular rate and rhythm. Pulmonary: Coarse bilaterally. Head and Neck Evaluation: Pupils are reactive. There is no thyromegaly or lymphadenopathy appreciated. She has normal neck range of motion. Musculoskeletal: Waddell’s signs are 3/5. There is mildly positive facet loading tenderness at the lumbosacral SI region. Negative straight leg extension test. Neurologic: Cranial nerves II through XII are intact. There is 5/5 upper and lower extremity strength noted. The gait is mildly antalgic, but she can get to the exam table unassisted. She leads with her left leg when doing so. There is some decreased sensation on the L3-L4 dermatome right leg versus left. There is easily appreciated 1-2/4 patellar and trace ankle jerk reflexes noted. Back Exam: Shows well-healed 3 to 4 inch low lumbar incision consistent with laminectomy and lumbar fusion. Extremities: Palpably warm. Tattoos noted. Homan’s sign is negative.

ASSESSMENT:1. Chronic pain, other.2. History of advanced lumbar spondylosis leading up to moderate-to-severe L3-L4 right-sided neural foraminal narrowing based on old lumbar MRI in this patient with a reassuring neurological exam.3. History of L4-L5 laminectomy and lumbar fusion – stable neurological exam.4. History of myofascial back pain.5. History of methamphetamine and marijuana use as documented by my practice partner.6. History of anxiety, ADHD, other psychiatric issues following up with un-recalled psychiatrist.

PLAN: I reviewed the pain management options with your patient for about 50 minutes. Typically she would have followed up with my practice partner who got to know her back in 2012, but I gather due to some type of failed therapeutic relationship she wanted to be seen by me today. I let her know that I agree with my practice partner that she is a high risk candidate to be on habit-forming / controlled substance pain medications. She does not seem particularly interested in taking pain medications, but then goes on to point out that she has trialed numerous other options — all with limited treatment gain. In summary she does not see any other viable alternative. In any event, I advocated a stepwise approach.

INTERVENTIONAL PROCEDURES: The patient does report significant relief after (what she thinks to be) a lumbar epidural offered by another local pain management physician years ago. With this thinking in mind I had the patient sign a release of medical records to understand what injections were offered and what her treatment response was. Tentatively she is interested in trialing L3-L4 lumbar epidural and we will tentatively schedule this, but I also recommended that we get updated imaging to give her the best chance of success with further injections.

ADDITIONAL STUDIES: I provided the patient a referral for lumbar MRI with and without contrast to characterize the etiologic factors in her current pain presentation. Her old lumbar MRI does show epidural fibrosis and moderate-to-severe narrowing at the L3-L4 neural foramen so we will tentatively schedule lumbar epidural at this level, but modify the plan as indicated by the upcoming MRI.

PAIN MEDICATIONS: The patient did inquire about a Soma prescription, but I recommend against it. Of all the muscle relaxers that is the one that can be habit forming. Given that she has prior illicit drug use and is considered a high risk candidate to remain on controlled substance pain medications, I recommended against that. I did give her trial prescription for Flexeril. She points out ibuprofen helps more than Celebrex. I explained to her why NSAIDs should probably be avoided given her history of bariatric surgery, but in the short run I gather she is tolerating them. It would probably be a good idea to add GI prophylaxis if she remains on them longer term though.

ACTIVITY MODIFICATION/PHYSICAL THERAPY: I generally counseled the patient that one of the primary goals of the injections and her further workup would be that of characterizing her pain so hopefully she can make more progress with physical therapy. She would likely benefit from the Reading Hospital Behavioral Science Clinic, where she could focus on psychological support strategies and further develop physical therapy program.

ADDITIONAL CONCERNS: Today the patient also complains of mid back pain. She has a history of lumbar thoracic scoliosis that is fairly subtle on physical exam. I gave her a referral for plain x-ray imaging of the thoracic spine to assess further. We will follow up on that study and plan appropriately. Certainly, it was a pleasure meeting your patient here at Center for Pain Control today. Thank you for allowing me to participate in the care of this pleasant patient.

Sincerely,Jason T. Bundy, M.D.

continued from page 17Chief Complaint

S P R I N G 2 0 1 6 | 1 9

CHIEF COMPLAINT:6/10 back, right anterior lateral thigh pain.

Dear Dr.:

Your patient follows up six weeks after her initial consultation evaluation on January 4, 2016. On that day, she was complaining of severe back, right leg pain. It was recognized she has a history of an L4-L5 lumbar fusion. She had followed up with another pain management physician over the years who had offered lumbar epidurals with variable treatment gain. Recognizing all of it, we decided to update her lumbar MRI. Lumbar MRI 01/20/2016, “posterior spinal fusion decompression L4-L5. Multilevel degenerative change, spinal stenosis most predominant at L2-L3 and L3-L4. Neural foraminal narrowing most predominant right L2-L3 and right L3-L4 and bilaterally L5-S1.” Basically, I offered to proceed to a right-sided lumbar epidural injection, but due to the patient’s deductible cost she is just simply unable to afford that option at this point. I offered for her to fill out charity care forms and she is going to look into that. In the meantime: Along the way, the patient has trialed various pain medications with some limited relief. When I last saw her she requested a

prescription for Soma. I clearly recognized her as a high risk candidate to remain on controlled substance pain medications given her prior history of illicit drug use as documented by my practice partner. In fact, my practice partner refused to prescribe opioids to her years ago and she subsequently followed up elsewhere to remain on them. Given her history of bariatric surgery, she really is not a candidate to remain on NSAIDs. She has trialed antineuropathics with a lot of side effects. She further alludes the fact that she was given a temporary prescription for Percocet by another provider in a urgent care center about a month and a half ago. She further states that she has been using those with treatment effect and would like an updated prescription for Percocet. This is discussed below.

Interval PMH/SH/FH/SH: Not otherwise changed. The patient is disabled and states her back pain is very rate limiting.

Current Medications: None reported on her intake form. (When the patient was confronted with a urine drug screen, she admits to using Percocet, as prescribed by an unrecalled urgent care physician and also smoking marijuana for her birthday.) Allergies: Morphine, Fentanyl. Hallucinations on OxyContin.

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Family Medicine and Internal Medicine Specialists

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continued from page 19Chief Complaint

Review of Systems: She reports severe burning dysesthesias in the right thigh. She denies progressive weakness, recent history of trauma or fall. Initially she denies a history of illicit drug use but then later on in the encounter admits to marijuana use when confronted with a urine drug screen.

February 19, 2016Page 2

PE: General: Alert and oriented x 3, in no acute distress, very pleasant, fairly forthright historian. Psychiatric: Mood is okay. Affect appropriate. Musculoskeletal: There is positive lumbar facet loading, tenderness lateral to an otherwise well healed lumbar incision. There is some mildly positive right straight leg extension test negative on the left. Neurologic: Cranial nerves II to XII are intact. There is 5/5 upper and lower extremity strength noted. Gait is moderately antalgic. Her station is forward leaning. Back Exam: Shows well healed incision. There is no obvious deformity. Extremities: Palpably warm. There is no obvious size or length discrepancy.

S P R I N G 2 0 1 6 | 2 1

ASSESSMENT:1. Chronic pain, other.2. Advancing multilevel lumbar degenerative disk disease, facet arthropathy resulting now in right greater than left severe L2-L3, L3-L4 neural foraminal narrowing in this patient clinically complaining of right-sided predominant radicular pain.3. History of illicit drug use in the past and recently.4. History of bariatric surgery – not an ideal candidate for NSAIDs.5. Status post L4-L5 laminectomy lumbar fusion – stable neurological exam.6. Myofascial back pain.7. History of anxiety, ADHD, prior history of abuse and other psychiatric issues. The patient follows up inconsistently with an un-recollected psychiatrist periodically, but due to cost issues, following-up for routine medical care is a challenge for this patient.

PLAN:I reviewed the pain management options with your patient for about 35 minutes. Once again I emphasized a multimodal approach and also clearly recognized there is no easy answer here. The patient is considered a high risk candidate to remain on controlled substance pain medications, but given the cost issues of pursuing alternatives, she would basically like to remain on them. I encouraged her to go ahead and check into filling out charity care forms. In the meantime:

PAIN MEDICATIONS: The patient once again inquired about a prescription for Soma and once again I recommended against it because this is one of the few muscle relaxers that can be habit forming. She inquired about a prescription for Robaxin and I did give her that. We carefully weighed the risks and benefits of titrating opioids. She self discloses a prior history of methamphetamine / marijuana abuse in the 1980s. She indicated she was not using any illicit drugs or taking prescription pain medications, but then when confronted with a routine urine drug screen her story changed. I counseled it is absolutely unacceptable for her not to disclose her current pain medication use and/or illicit drug use to her care providers. She voiced understanding and was fairly contrite. Recognizing all of it and giving her the benefit of the doubt this time, I was still willing to give her 60 tablets of Nucynta 50 mg tablet one tablet to be taken q. 8h. as needed for pain. We did collect a urine sample and had her sign our practice opioid agreement. We will monitor this patient quite closely. If she further violates the opioid agreement we will not continue any controlled substance pain medications. She voiced clear understanding of that.

INTERVENTIONAL PROCEDURES: I did counsel the patient she would likely benefit from a right-sided L2-L3 and L3-L4 transforaminal epidural injection. For now, she is electing to hold off on that, but again I encouraged her to consider filling out charity care forms. Down the road, I mentioned a spinal cord stimulator strategy could help her if the lumbar epidural truly fails to provide durable relief. I mentioned that she could always check back in with her spine surgeon, but I gather she was deemed a non-reoperation candidate in the past and she is not particularly interested in that option anyway.

ACTIVITY MODIFICATION/PHYSICAL THERAPY: Once again I discussed a referral to the Reading Health System Behavioral Science Clinic where she could focus on psychological support strategies and develop a physical therapy program. Due to cost issues, she elects to hold off on this program for now. Certainly, it was a pleasure meeting your patient here at Center for Pain Control today. Thank you for allowing me to participate in the care of this pleasant patient.

Sincerely,Jason T. Bundy, M.D.

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The following was submitted for publication by the Reading Caduceus Group of

Alcoholics AnonymousMeeting Saturdays at 8 am at the

“Old Wyomissing Borough Hall” at the corner of Penn Ave and Wyomissing Blvd next to

Atonement Lutheran Church

(Editor’s note: A Caduceus Group is a Healthcare

Professionals addiction support group. Participation is one

component of the Physicians’ Health Programs of

The Foundation of the Pennsylvania Medical Society.)

Reading Area Contact Numbers for meeting

list and rides:

Narcotics Anonymous – 610-374-5944

National Suicide Prevention Line – 800-273-8255

Alcoholics Anonymous – 610-373-6500

Al-Anon – 610-373-5237

T H E S E P R O G R A M S A R E F R E E T O A L L

ABSTINENCE PROGRAMS

Me d i c a l Re c o R d Fe at u R e

WHAT IS THE NARCOTICS ANONYMOUS PROGRAM?

NA is a nonprofit fellowship or society of men and women for whom drugs had become a major problem. We are recovering addicts who meet regularly to help each other stay clean. This is

a program of complete abstinence from all drugs. There is only one requirement for membership, the desire to stop using. We suggest that you keep an open mind and give yourself a break. Our program is a set of principles written so simply that we can follow them in our daily lives. The most important thing about them is that they work. There are no strings attached to NA. We are not affiliated with any other organizations. We have no initiation fees or dues, no pledges to sign, no promises to make to anyone. We are not connected with any political, religious, or law enforcement groups, and are under no surveillance at any time. Anyone may join us regardless of age, race, sexual identity, creed, religion, or lack of religion. We are not interested in what or how much you used or who your connections were, what you have done in the past, how much or how little you have, but only in what you want to do about your problem and how we can help. The newcomer is the most important person at any meeting, because we can only keep what we have by giving it away. We have learned from our group experience that those who keep coming to our meetings regularly stay clean.

Reprinted by permission of NA World Services, Inc. All rights reserved. Copyright 1986 by Narcotics Anonymous World Services, Inc., PO Box 999, Van Nuys, CA 91409ISBN 0-912075-65-1 10/00

S P R I N G 2 0 1 6 | 2 3

ALCOHOLICS ANONYMOUS PREAMBLE©

Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self -supporting through our own contributions. A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.

Copyright © The AA Grapevine, Inc.Reprinted with permission

AL-ANON PREAMBLE TO THE TWELVE STEPS

The Al-Anon Family Groups are a fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems. We believe alcoholism is a family illness and that changed attitudes can aid recovery. Al-Anon is not allied with any sect, denomination, political entity, organization, or institution; does not engage in any controversy; neither endorses nor opposes any cause. There are no dues for membership. Al-Anon is self-supporting through its own voluntary contributions. Al-Anon has but one purpose: to help families of alcoholics. We do this by practicing the Twelve Steps, by welcoming and giving comfort to families of alcoholics, and by giving understanding and encouragement to the alcoholic.

Reprinted with permission of Al-Anon Family Group Headquarters, Inc., Virginia Beach, VA. Permission for the reprint of the above-described material with the above terms and conditions and on the Web site identified above is hereby granted by: Al-Anon Family Group Headquarters, Inc., 1600 Corporate Landing Parkway, Virginia Beach, VA 23454-5617 | (757) 563-1600 | (757) 563-1655 (fax) ©2006-16 Pennsylvania Area Assembly

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WHY IS ORAL HEALTH SO IMPORTANT TO THE MEDICAL COMMUNITY?

• Oral health is essential to overall health! • Tooth decay is a serious, but preventable chronic infectious disease.• One in four U.S. children between 2-4 years of age has tooth decay. • Tooth decay is seven times more common than asthma.• Untreated tooth decay negatively impacts children’s growth and development and makes it difficult for young children to eat, speak, play, learn and be successful in school. • While children from low-income and minority families are at higher risk, all children under age 5 are experiencing more tooth decay today than ever before (The American Academy of Pediatric Dentistry, State of Little Teeth). • Prevention of tooth decay requires daily oral hygiene, tooth healthy foods and beverages, and regular professional dental care. • Children with special healthcare needs (e.g., asthma, obesity, epilepsy, cerebral palsy, autism, etc.) are especially vulnerable to early childhood caries. This can be prevented if they are referred to the dentist as soon as the first tooth comes in.

PROGRESS IN PENNSYLVANIA – PROFESSIONAL DEVELOPMENT FOR YOU

Funded by the DentaQuest Foundation, the Pennsylvania Oral Health Collective Impact Initiative is an exciting collective collaboration between the PA Head Start Association, the PA Association of Community Health Centers, the PA Coalition for Oral Health, and the PA Chapter of the American Academy of Pediatrics, focused on the goal of eliminating dental disease in young children across our state. As a result of this collaboration, several professional development courses for ECE practitioners are available to help you learn more about the oral health of children in your care, including:

• Healthy Teeth Healthy Children: Oral Health in Your Office (1-1.5 hours) presented FREE to your office staff. Qualifies physicians to bill PA Medicaid for fluoride varnish application [commercial insurances do not have this requirement – just use CPT code 99188 for both commercial and PA Medicaid billing now!]. Call 484-446-3059 and speak with Kristin Haegele-Hill to arrange for the presentation [or email khaegelehill@paaap.org].

o Be sure to start applying fluoride varnish when the first tooth erupts and four times per year. This fluoride is not absorbed and if applied more frequently will do no harm. Medical providers can do this and refer the child to the dentist for additional care.

updateOral Health

Me d i c a l Re c o R d Fe at u R e

by C Eve J Kimball, MD

S P R I N G 2 0 1 6 | 2 5

o Dental sealants must be applied when the permanent molars erupt to protect them. This must be done by the dentist.

• Cavity Free Kids (2-3 hours): this curriculum educates early learning practitioners (and medical staff!), children, and families about oral health through hands-on activities, songs, and lesson plans. Contact Amy Requa at amyrequa@paheadstart.org for more information.• ECELS [Early Childhood Education Learning System] has several offerings for child care centers available at www.ecels-healthychildcarepa.org:

1. Listen to and complete the ECELS Oral Health Webinar (1.5 hours) 2. Complete the ECELS Oral Health Basics Self-Learning Module (1 hour)3. Complete the ECELS Oral Health Self-Learning Module (2 hours)

For more information on the Pennsylvania Oral Health Collective Impact Initiative, please watch our informational video: https://vimeo.com/149015009.

WHAT ELSE CAN YOU DO?

Help prevent dental disease in children in your care by using these simple strategies:

• Download and share “Brush Up On Oral Health” newsletters with parents: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ health/oral-health/policies-procedures/buoh.html• Order free Think Teeth resources to share with parents: https://www.insurekidsnow.gov/professionals/dental/index. html• Use this colorful Oral Health poster: http://www.ecels- healthychildcarepa.org/tools/posters/item/431-oral-health- poster • Engage children in tooth brushing routines using the Classroom Circle Brushing poster to guide you: http://www. ecels-healthychildcarepa.org/tools/posters• Use dental health campaign materials from the Ad Council at: http://www.adcouncil.org/Our-Campaigns/Health/Children-s- Oral-Health• Play the Brush My Smile (Choosy Kids) video for children and parents, or post it on your Facebook: https://www.youtube. com/watch?v=4rStiY7GDdY • Help families get oral health care services for their children: www.insurekidsnow.org and www.aapd.org

To learn more about the Pennsylvania Oral Health Collective Impact Initiative or for more resources to improve oral health for children, please contact:

• Healthy Teeth, Healthy Children Program at the PA Chapter, American Academy of Pediatrics: http://www. healthyteethhealthychildren.org/ Kristin Haegele Hill, Program Director, hthc@paaap.org• ECELS: ecels@paaap.org or (800) 243-2357 • PA Head Start’s Oral Health Initiative: Healthy Smiles, Happy Children: A Dentist for Every Child. Amy Requa, State Oral Health Coordinator, amyrequa@paheadstart.org• PA Coalition for Oral Health: www.paoralhealth.org Lisa Schildhorn, Executive Director, paoralhealthinfo@gmail.com• PA Association of Community Health Centers: www.pachc.org Ed Franchi, Special Projects Coordinator, ed@pachc.org

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(Harrisburg, Pa. – 3/1/16)

Today, it’s a well-known fact that prescription drug abuse is a public health crisis across the country. With politicians now jumping into the fight with their

personal ideas on how best to tackle the issue, what was once invisible is now a front page headline with more and more Americans being personally touched by the loss of family and friends. In Pennsylvania, few took notice to the silent epidemic before deaths from prescription drug abuse started making the front pages of newspapers across the state. And, in fact, there was no reason to believe opioids would create such a problem particularly when Purdue Pharma launched a campaign in 1996 informing patients and doctors that a new, safe drug was available to combat pain. But, there were some early warning signs and some did begin to take notice. Unfortunately, despite their best efforts at raising red flags, moving legislation was difficult if not impossible at the time. During the 2011-’12 legislative session, with 45 co-sponsors including prime sponsor Eugene DiGirolamo, Pennsylvania House Bill 1651 aimed to establish the “Pharmaceutical Accountability Monitoring System.” This would give physicians a tool to better understand if the person

sitting in their exam room had legitimate pain or was doctor shopping. Sadly, the bill never received a vote on the floor of the state house of representatives. “It was disappointing back then that no one would listen,” says Scott Shapiro, MD, president of the Pennsylvania Medical Society. “Members were coming to us and indicating that doctor shopping seemed to be increasing. They suspected an increasing number of addictions. We knew something had to be done.” With a new legislative session on the horizon, according to Dr. Shapiro, this time the medical society was determined to see legislation move and became considerably more vocal. “We knew that this silent epidemic was going to get worse before it got better, and we knew we had to be louder if we were going to be successful,” Dr. Shapiro says, explaining leadership at the Pennsylvania Medical Society directed staff to launch a campaign just prior to the 2012-’13 legislative session to push for a controlled substance database. “That’s how our ‘Pills for Ills, Not Thrills’ campaign got started,” he says. “It was a complete push using all of our communications and government affairs tools available – news releases, editorials, educational materials, and meetings with legislators.”

Tracking the Tracker: The Long Road for

Pennsylvania’s Prescription Drug Monitoring Program

Me d i c a l Re c o R d Fe at u R e

S P R I N G 2 0 1 6 | 2 7

continued on next page >

How Did This Epidemic Grow? York County in beautiful southcentral Pennsylvania is dealing with one of the larger number of overdose deaths in the state. According to a DEA Intelligence Report, York County had 118 drug-related overdose deaths in 2014, nearly double any neighboring county. With stereotypes in mind, it’s a county that many would not think of being among the worst in the state. Its unemployment rate is near the average for Pennsylvania and the graduation rate of nearly all high schools is above the state average. This rural county with 85 percent of its population being white wouldn’t seem to be a hotbed of drug problems. Drug statistics say otherwise. In 2014, of the 118 deaths, 111 were white. And, combining all races, 48 of those who died were between the ages of 31 and 45. “Not too many people would think this is a rural health issue, but it happens here too,” says Bradley Levin, M.D., FACC, FACS, FASAM, DABAM, CMRO, of York County Medical Society. He is a member of the York County Heroin Task Force. Illicit drugs like heroin and marijuana are most often present in drug-related overdose deaths, but opioids are part of the picture 33 percent of the time. According to York County Coroner Pam Gay, 2015 is likely to be similar to 2014 with its end of year statistics of 65 heroin-related deaths out of 95 drug deaths overall (with a few still pending). But Gay points out repeatedly that without Law Enforcement administering Naloxone in York County in 2015 (from April to December 2015), and the subsequent 99 saves that resulted, there would likely have been dozens more heroin-related deaths in York County in 2015. So how did York County get to where it is at today? Dr. Levin says that this problem grew out of another issue – managing pain. In mid-February 2016, Modern Healthcare took a closer look at the root of the problem and traces it back to 1996 when Purdue Pharma began promoting a new drug to fight pain – OxyContin. Early on, the medication was billed as being safe because it would slowly release narcotic ingredients, making it unlikely to become addictive. “We were told that this new drug would be the answer to many issues related to pain, particularly since a year earlier pain became the fifth vital sign and the American Pain Society recommended it be added to the indicators that assess overall health,” says Dr. Levin, mentioning there was even a time when physicians would be penalized for not prescribing opioids. But Dr. Levin adds that problems were brewing. Nearly 10 years later in 2007 Purdue would plead guilty in federal court to criminal charges that they misled regulators, doctors, and patients about the drug’s risk of addiction as well as its potential to be abused. “We know better today, but the beast was unleashed and as addictions grew so did doctor shopping and other illegal activities,” says Dr. Levin. “Those seeking pills got really good at finding what they wanted and in some cases pushed the drug out onto the street.”

According to the National Institute on Drug Abuse, the most popular source for non-medically used prescription drugs are friends and relatives with 54.2 percent receiving them for free and another 16.6 percent either stealing or purchasing the drug. NIDA estimates that 6.1 million Americans are using prescription drugs for non-medical reasons every month. Gaining Momentum Dr. Todd Fijewski, President of the Pennsylvania College of Emergency Physicians, has had a front-row seat in this growing epidemic. He’s seen his share of drug overdoses, infections secondary to drug use, and deaths. Addiction can affect anyone. It does not discriminate. “It’s pretty safe to say that if you work in emergency medicine, you’ve seen more than enough overdose victims,” says Dr. Fijewski. “It’s a problem that impacts so many different types of people, whether you live in rural or urban settings.” His organization too saw an urgent need for more tools to help physicians fight prescription drug abuse and like the Pennsylvania Medical Society was an active member of the choir calling for the state to pass legislation to give physicians access to a controlled substance database. He says, after the failure of HB 1651, clearly what was once a silent epidemic was becoming quite visible.

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“It was getting hard to ignore,” Dr. Fijewski says. “There was suddenly a greater awareness of the issue and the media made it clear that Pennsylvania lagged behind other states in passing prescription drug monitoring legislation.” Fortunately, the issue had more heroes stepping up in Harrisburg. Rep. Matt Baker teamed up with Rep. DiGirolamo and others to push House Bill 1694 to a successful 191-7 vote in October 2013. At about the same time, Sen. Pat Vance had Senate Bill 1180 introduced and moving as well. Her bill ultimately would be the bill to cross the finish line on October 27, 2014, when then-Governor Tom Corbett signed it into law. Prior to Gov. Corbett’s signature, SB 1180 passed the Senate 47-2 and the House 194-2. SB 1180 established the Achieving Better Care by Monitoring All Prescriptions Program (ABC-MAP) and was scheduled to be in place by mid-2015.

Pennsylvania Medical Society Tips In Pennsylvania, locations have been set up throughout the state for residents to dispose of medications they no longer need. A complete list of locations can be found at https://apps.ddap.pa.gov/GetHelpNow/PillDrop.aspx.

The Pennsylvania Medical Society offers the following tips when disposing of unused medications:

• Add medicine cabinets to your list of Spring Cleaning Projects.

• Get rid of medications you no longer use by dropping them off at a designated take-back location.

• Unless instructed to do so, do not flush medicine down toilets.

• Leave medications in their bottles when visiting a take-back location.

• Remove all personal information from the bottle’s label before disposing.

This news release is brought to you by the Pennsylvania Health News Service Project, consisting of 21 Pennsylvania-based medical and specialty associations and societies. See more at: http://www.pamedsoc.org/FunctionalCategories/About/Media/March-PHNS.

html#sthash.jO75SvPh.dpuf. Inquiries about PHNS can be directed to Chuck Moran via the Pennsylvania Medical Societyat (717) 558-7820, cmoran@pamedsoc.org, or via Twitter @ChuckMoran7.

More help, but still waiting Since October 2014, other in-state initiatives to address opioid abuse were developed. Medication drop boxes are available throughout the state. Pennsylvania Physician General Rachel Levine signed a statewide prescription for Naloxone, a life-saving drug that has the power to reverse an overdose. Physician education to correct pharmaceutical misinformation from years earlier also became important. Opioid prescribing guidelines were developed by groups like the Pennsylvania Medical Society, Pennsylvania College of Emergency Physicians, Pennsylvania Department of Health, and Pennsylvania Department of Drug and Alcohol Programs. And continuing medical education specific to opioid prescribing has been developed by multiple medical organizations. But, despite the success of SB 1180 in 2014 and the high awareness level of the state’s opioid abuse crisis, Pennsylvania physicians continue to practice without that extra arrow in their quiver. To date, Pennsylvania’s prescription drug monitoring tool has yet to go live. But progress is being made. During a mid-February meeting of the ABC-MAP Board, the Pennsylvania Department of Health introduced the project vendor – Appriss, which manufactures the PMP AWARxE system. Currently 23 states utilize Appriss’ PMP solution. Additionally, Appriss is the company that the National Association of Boards of Pharmacy used to create and manage their PMP InterConnect system, which facilitates interoperability and interstate data sharing between prescription monitoring programs. Sources inside the Pennsylvania Medical Society are hopeful for the system to be delivered to the state during the summer months and available for physician use shortly later. “When you factor in all that health care professionals and state officials are doing, there likely is no other public health issue in Pennsylvania getting as much attention,” says Lawrence John, MD, president of the Allegheny County Medical Society and a family physician in Pittsburgh. “This crisis hit us like a tidal wave. It was the perfect storm of misunderstanding at a time when pain was being undermanaged. Time has shown us more now than we were able to see back then about the potential for misuse and abuse.” Pennsylvania Medical Society’s Dr. Shapiro agrees, and adds, “It’s going to take some time to see the benefits of all these initiatives, but we are on the right path and we will see results.”

continued from page 27Tracking the Tracker: The Long Road for Pennsylvania’s Prescription Drug Monitoring Program

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Me d i c a l Re c o R d Fe at u R e

On October 25th, 2015, the PAMED House of Delegates adopted Resolution 15-501, requiring the Board of Trustees to create a task force to examine the feasibility of forming

larger regional medical societies built upon the existing structure of the county societies, with the goal of continuing to provide appropriate representation of physicians’ local issues while providing increased member benefits through the pooling of resources. Consequently, on February 9th, 2016, the PAMED Board of Trustees approved the creation of a task force, to be chaired by Charles Cutler, MD, and the appropriation of funds to contract with a consultant that is highly regarded for work in the association and membership fields. The focus of the consultant’s work will be to look at the issue of dues pricing relative to value and willingness to pay as that will directly impact the cost analysis of the feasibility of regionalization. The task force, with the help of the consultant, will deliver a report to the Board later this year, which will then be presented to the House of Delegates on October 22nd, 2016. This is important work, and we look forward to reading the task force’s findings, but this begs a fundamental question that I wish to pose: What is the purpose of the county medical society? What has worked in the past, and what didn’t? What works now and what doesn’t? Where should we go from here? These are healthy questions for any organization undergoing change, and although PAMED is an appropriate venue to discuss regionalization, it must be discussed locally, in each county, as well. Each county’s medical society is an independent professional association, with its own history. They are not subsidiaries of PAMED, just as PAMED is not a subsidiary of the AMA. The relationships are best described as interdependent, as it is difficult to imagine a healthy state society without engaged county societies, or a vibrant national society without strong state societies. Although

independent in one sense, the success of one is dependent on the success of the others. In short, this is a partnership, and any fruitful discussion of regionalization requires the participation of the counties. The Dauphin County Medical Society (DCMS), of whom I am privileged to serve as Vice President, has a rich history, being founded on February 20th, 1866. Its original mission, speaking broadly, was to help maintain the AMA and PAMED, which were founded in 1847 and 1848, respectively. More specifically, DCMS’s mission was to extend medical knowledge, advance medical science, elevate and maintain the standards of medical education, uphold the ethics and dignity of the medical profession, foster partnerships between physicians and the communities they serve, and promote public health and hygiene in the prevention and management of disease. Over time, a number of changes have occurred. As a county medical society, DCMS is no longer focused on advancing medical science or improving medical education standards because those missions, although important, are not best suited to a county medical society. Today, DCMS’s mission is to uphold the ethics and dignity of the medical profession, elevate and maintain the highest standards of healthcare, promote and disseminate medical information to members and the public, and promote collegial relations among our members. I’m sure many of the other county medical societies have similar missions, and also have a history of their missions changing as the needs of their members changed. A thoughtful discussion of regionalization requires deciding on a clear mission for those societies. Organizations have official mission statements to publicly communicate their ideals and what they hope to achieve. But it is also useful to look at the unwritten mission statement of an organization, what is it actually doing and what do its members

To be, or not to be – the role of the county medical society

by Heath B Mackley, MD, FACRO

want it to do, and to see how that matches the formal mission. Broadly speaking, the activities of DCMS are focused on maintaining a community for physicians that crosses health systems and employment statuses, advocating for patient and physician causes in the legislative and regulatory spheres, offering continuing medical education on select topics, giving of ourselves in community outreach and philanthropy, and providing a conduit for Dauphin County members to become involved in the work of PAMED. I have had the good fortune of meeting and working with other county societies in the 5th district, including Berks, Lancaster, and York, and these county societies are also very active, making their communities and PAMED better in the process. But not all county societies are active. Even if they have an attractive mission statement, what message is that saying to the public, and what value are they providing to their members? Would physicians in nearby counties with non-active county societies be better served by being a member of a regional society that would have as a foundation the strengths of the active county societies? Or would this dilute the community that the strong county societies are trying to foster, and hurt membership by alienating members that appropriately cherish, and take pride in, the rich histories of the county medical society? And then there is the elephant in the room, money. Within the group of inactive county societies, some collect dues, and some do not. For PAMED to continue to thrive, it has to consider adjusting its own dues structure, yet it has no direct control over county societies which set their own dues, and that is part of the price tag that physicians see. PAMED requires its members to be a member of a county society, but this is a choice, not a mandate. In 1995, PAMED ceased to require AMA membership for its members. It is possible for PAMED to do something similar with the counties, but it’s hard to see that as anything other than harmful to county membership. Would that be in PAMED’s best interest? “Softer” measures could include exerting influence over county dues rates by making PAMED’s collection of county dues on their behalf contingent on specific conditions. Given the likelihood that less than 100% of counties would be compliant, this would lead to a schism of sorts between the “cooperative” counties and the “uncooperative.” It is also worth noting that the majority of many county society’s budgets are for professional support staff, most of whom are PAMED employees, so any effort that significantly decreases county income could lead to PAMED needing to either downsize or reassign those positions. All of this underscores the interdependence of PAMED and its county societies, and their collective need to be partners in any process that considers major changes that affect both. This article is not a sound of alarm about impending changes, nor is it a recommendation on adopting a specific policy. This is a call to open the lines of discussion as broadly as possible. I see the county medical societies and PAMED engaged in important work each and every day. But what do we need to do to thrive in the future? Let us know your thoughts! We need your involvement more than ever!

Dr. Mackley is a Radiation Oncologist at the Penn State Hershey Cancer Institute and 5th District Trustee, representing physicians of this county.

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th e Fo u n d at i o n o F t h e Pe n n s y lva n i a me d i c a l so c i e t y

The Foundation of the Pennsylvania Medical Society celebrates the

30th anniversary of the Physicians’ Health Program (PHP) by sharing 30 stories of how the program changed people’s lives. Here are some excerpts from a few of them:

When my husband’s alcoholism came to light, he went into a rehab center and I went into a crisis. It felt like a hand-grenade had gone off in my living room, and the pieces of my life were flying around me like shrapnel and debris. I honestly didn’t know what to hold onto, and what to let blow away. The counselor at the rehab center recommended that I get in touch with the PHP to learn about the voluntary monitoring program for physicians. Although I was reluctant to share our family secrets and to ask for the help that we needed, I found the phone number on the Internet and called the PHP while my husband was still in inpatient treatment. The reception I got from the PHP was warm and welcoming. I realized that I didn’t have to find my own way, because others had gone before me on this path. When I told the PHP counselor that my plan for my husband after his rehab discharge was to administer a breathalyzer test before he went to work, when he came home, before he drove with the kids, etc., I was quite wisely told that I couldn’t be a spouse and the sobriety police. What would I do if my husband kept drinking? How could I enforce these rules? What would happen with empty threats and ultimatums that might not work? I listened to the information about their program and started to have hope that I wouldn’t be alone to shoulder the burden of living with an alcoholic.

Fast forward two years, and our family is doing well. I attend Al-anon meetings, and have found a whole group of people who understand this disease. I have learned that I am not responsible for anyone else’s drinking or sobriety. My husband has a strong AA program and attends 5-6 meetings per week. He has maintained his sobriety by using all the tools available, one of which is the PHP monitoring program. He has random blood and urine tests, and follows the program requirements of meetings and counseling. We don’t look at these program requirements as an intrusion or a punishment. Instead, they are a welcome means of accountability. It is a way to reestablish trust and prove that he can “walk the walk” as well as “talk the talk.” Alcoholism can’t be cured, but it’s a disease that can be managed with the right strategy. I am grateful to the PHP for helping us live with alcoholism.

—Tina Fell

Oct. 12, 1988: DEA agents invaded my home in search of evidence regarding distribution of controlled substances. More than 70,000 doses were registered to me and not accounted for. That day was the first time I ever admitted (to the agents) that I was a drug addict. They had “other ideas.” This was the end of life as I knew it. My Pennsylvania medical license and DEA registration were suspended/revoked, as were my hospital privileges. Felony charges were issued three years later. I had to stop using narcotics, and that was not possible.

S P R I N G 2 0 1 6 | 3 3

S A V I N G L I V E S A N D C A R E E R S For 30 years, the PHP has helped more than 3,000 physicians enjoy life without drugs or alcohol and continue to be successful physicians. To learn how you can make a difference by contributing to the PHP Endowment, contact Marjorie Lamberson, CFRE, at mlamberson@pamedsoc.org or (717) 558-7846. Or, mail your gift to:

The Foundation of the Pennsylvania Medical SocietyPhysicians’ Health Program Endowment Campaign777 East Park DriveP.O. Box 8820Harrisburg, PA 17105-8820

On Oct. 14, two days later, knowing that my supply was frighteningly low, I did prepare for suicide. I prepared two syringes, one with Midazolam and one filled with Pavulon, and placed them in my top drawer. That same day, an old acquaintance of mine who had previously been in much trouble accepted my call. He gave me a phone number and said, “You do not have to feel this way anymore. Life can be beyond your wildest dreams.” The phone number was for the PHP. I spoke somewhat honestly for the first time about my addiction. They sent a gentleman to my home to escort me to Marworth, a rehabilitation facility. I have been involved with the PHP as a participant, monitor, and committee member for the past 27-plus years, with continuous sobriety since Day One. PHP provided the framework for my recovery, monitoring, and letters of support whenever needed. I owe them my life. I resumed practicing anesthesia in 1989 and have been professionally successful since that time. This is a direct result of PHP intervention. My story is a miracle. My path would not have been feasible without the support and guidance of PHP.

—Dean Steinberg, MDcontinued on next page >

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As a medical student, my experience in the PHP has been quite interesting. Initially, I was hesitant, mainly because I had never imagined myself in a program like this. However, after almost a year in the PHP, I can honestly say that this program is the best thing that has ever happened to me. My family and closest friends constantly remind me how much better I am since joining the PHP. The staff is very kind, and it is clear that they care about you and your well-being. My most memorable patient experience that reminded me how great the program has been for me was on my psychiatric rotation. I was talking to one of my patients, and another patient happened to be sitting at the table with us. I had never met her before and I felt a very unique connection and understanding with her. She mentioned that she no longer drinks because no one likes being around her when she drinks. This patient went on describing her story, and I was able to relate on a very personal level. I understood her intimately, as my family and friends have been telling me how great I am to be around since I’ve stopped drinking. Through the PHP, I feel like I am finally in a place where I have always wanted to be. I feel happier than I ever have before. Mainly, I am grateful to PHP for making me a better person, and I know I will be a better doctor.

— Anonymous

Go to www.foundationpamedsoc.org throughout the year to read new stories every month and donate online.

The Physicians’ Health Program (PHP), a program of The Foundation of the

Pennsylvania Medical Society, the charitable arm of PAMED, provides support and

advocacy to physicians struggling with addiction or physical or mental challenges.

The program also offers information and support to the families of impaired

physicians and encourages their involvement in the recovery process.

continued from page 33Physicians Health Program

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5 Important HR Issues to Monitor for 2016

DID YOU KNOW?  

Recent surveys show that employees are feeling more confident about their ability to make job changes, due to the improving economy. To help retain and attract top talent, now may be a good time for you to determine if your organization is offering a benefits package that is competitive. Conducting an employee benefits survey can help you discover what your employees really value.

   

Human Resources tips brought to you by Power Kunkle Benefits Consulting

 When conducting a survey, participation is key. Make sure the purpose of the survey is clear, and create a strong communication strategy. Always share survey results with employees and follow up on how the feedback will be implemented. Contact Power Kunkle Benefits Consulting for assistance.

   

April 2015        

 

Employee Handbook Spring Cleaning  

Now that benefits open enrollment is finished, you may want to consider dusting off your employee handbooks for an annual review. Regularly reviewing employment policies and procedures is becoming increasingly important as workplace legislation and regulations continue to change.

 Here are some things to consider when reviewing your employee handbook:

 • Make sure that internal company

policies and procedures are in line with actual practice. A policy that is not consistently enforced as it is written can become problematic if your organization is ever faced with litigation.

• Ensure that policies on harassment, discrimination, leave, drugs and alcohol, sexual harassment and background checks are updated to reflect the most current federal and state laws.

• Review the language in the handbook to ensure that your organization maintains

   

flexibility in interpreting and applying policies. Wherever possible, use general language (such as “may,” “typically,” etc.) in place of more limiting language.

• Make sure that the handbook includes a clear statement that the employment relationship is not a contract but “at will” and may be terminated at any time with or without cause.

• Determine if there are any local or state- specific policies that must be added or updated, such as paid sick leave.

• Consider updating the format and tone of the handbook to be consistent with desired company culture.

 The above are suggested starting points and not an all-inclusive list of things that you should consider. It is important for the handbook review to be a collaborative process that includes not only your human resources department, but also the managers and supervisors who are enforcing and interpreting the policies on a daily basis.  Lastly, it is highly recommended that you have legal counsel review your organization’s employee handbook. The National Labor Relations Board (NLRB) has recently claimed that many employer policies relating to employee conduct and social media are unlawful, which can result in terminated employees being reinstated and given back pay. Having an employment lawyer review the handbook can help your organization avoid costly litigation.

Final Rule—FMLA Protections for Same-sex Spouses  On Feb. 25, 2015, the Department of Labor (DOL) issued a final rule that expands protections under the federal Family and Medical Leave Act (FMLA) for same-sex spouses. This final rule, effective March 27, 2015, revises the definition of “spouse” under the FMLA to:  • Adopt a “place of celebration” rule,

which is based on where the marriage was entered into, in place of the “state of residence” rule that applied under prior DOL guidance; and

• Expressly include same-sex marriages in addition to common-law marriages and encompasses same- sex marriages entered into abroad that could have been entered into in at least one U.S. state.

 Under the final rule, eligible employees in legal same-sex marriages will be able to take FMLA leave to care for their spouses, regardless of where they live.  Employers should review and update their FMLA policies and procedures as necessary, and they should train employees who are involved in the leave management process on the expanded rules for same-sex spouses under the FMLA.

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Employers who are not prepared to comply with new employment laws may face civil fines, criminal penalties, administrative complaints, potential litigation and reputational harm.

Me d i c a l Re c o R d Fe at u R e

Employers have new challenges to contend with in 2016, resulting from Supreme Court decisions, federal and state legislation, and actions by federal

regulatory agencies. There is a real cost for employers who fail to comply with new laws. For example, the most recent Performance Accountability Report for the Equal Employment Opportunity Commission (EEOC), states that victims of discrimination received more than $525 million from private and government workplaces in 2015. The following are five important issues that should be closely monitored in 2016:

1. Overtime Rule Change: The Department of Labor (DOL) has proposed a rule to expand who is entitled to overtime pay. Once regulations are finalized, it is possible that many overtime-exempt employees will become eligible unless employers raise their salaries—a move that could cost employers billions of dollars.

2. Same-sex Marriage: Since same-sex marriage is now accepted at a federal level, employers are required to provide the same benefits to same-sex couples as they do for opposite-sex couples. Employers must revisit their policies and practices regarding Equal Employment Opportunity (EEO), employee benefits, leave policies, marriage statuses and tax information in order to ensure that they treat all married couples equally.

3. National Labor Relations Board (NLRB) Pursuit of Workplace Policies: The NLRB has been proactive in pursuing employers whose handbook policies can be reasonably interpreted as infringing upon the rights of employees to engage in protected conduct. In doing so, the NLRB has found that certain employer policies, such as those that deal with social media, confidentiality and employee communications, violate employee rights. Because of this development, current workplace policies should be reviewed and drafted carefully to avoid ambiguous language that could be interpreted as interfering with the right to engage in protected, concerted activity.

4. Paid Sick Leave: In 2015, President Obama issued an executive order providing paid sick leave for federal contractors. Paid sick leave laws continue to be passed on the state and local level as well. In fact, from 2014 to 2015, the number of state and municipal paid sick leave laws in the United States has more than doubled. It is important for employers to determine if any of these new laws apply to them and to update their policies to ensure compliance.

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5. Health Care Reform: Many employers are faced with the challenge of complying with the new annual health care reporting requirements under the Affordable Care Act (ACA). Applicable large employers (ALEs) and non-ALEs with self-insured plans were required to provide Forms 1095 or 1094 to their employees for the first time starting in 2016 for the 2015 tax year. Penalties for not doing so, or for providing inaccurate information, could be substantial. It is important for employers to know which forms to complete and what information to include.

Employers should also keep an eye on any relevant implications that might emerge as a result of the 2016 presidential election—specifically in regards to the Cadillac tax delay. Should the Cadillac tax go into effect in 2020, employers need to be sure that they are either ready to pay the tax or ready to make necessary changes to their health care plans. The aforementioned issues describe only a handful of the new HR changes that are forecasted for 2016. Contact Power Kunkle Benefits Consulting for more information on these issues and other HR-related questions.

This HR Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice. © 2016 Zywave, Inc. All rights reserved.

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Be r k s co u n t y me d i c a l so c i e t y al l i a n c e

Berks County Medical Society Alliance’s first meeting of 2016 was the annual Spring Meeting held this year at the home of member and Past President, Lisa Geyer. Our own Beth

Myers presented a talk entitled “Your Medical Marriage,” leading a dynamic discussion about the unique challenges and triumphs of physician marriages. Beth has been counseling married couples for 25 years, and we were very lucky to hear her compassionate and witty talk.

Of note also at the Spring meeting: the Alliance collected a carload of running shoes, socks, and sports bras to donate to one of our favorite local organizations: Berks Girls on the Run. In March, members and friends of the Alliance gathered at local pottery painting studio, Busy Bees in Wyomissing, to paint bowls to donate to the Opportunity House’s 14th Annual Souper Bowl, an annual fundraising and community event in which each person in attendance receives a handmade ceramic bowl along with a light meal of soup, bread and goodies from local restaurants and caterers. Meanwhile the Alliance Board is busy preparing the slate of new officers for installation later this Spring, and reviewing the applications for philanthropic grants and scholarships that will be awarded later this year. For more information about BCMSA, please check out: http://berkscmsa.org or “Like” us on Facebook!

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WHY READING HEALTH SYSTEM?

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