July/August 2023

Editor: James Santiago Grisolia, MD

Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; William T-C Tseng, MD; Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

Marketing & Production Manager: Jennifer Rohr

Art Director: Lisa Williams

Copy Editor: Adam Elder

OFFICERS

President: Nicholas (dr. Nick) J. Yphantides, MD, MPH

President–Elect: Steve H. Koh, MD

Secretary: Preeti S. Mehta, MD

Treasurer: Maria T. Carriedo-Ceniceros, MD

Immediate Past President: Toluwalase (Lase) A. Ajayi, MD

GEOGRAPHIC DIRECTORS

East County #1: Catherine A. Uchino, MD

Hillcrest #1: Kyle P. Edmonds, MD

Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair)

Kearny Mesa #1: Anthony E. Magit, MD, MPH

Kearny Mesa #2: Dustin H. Wailes, MD

La Jolla #1: Karrar H. Ali, DO, MPH (Board Representative to the Executive Committee)

La Jolla #2: David E.J. Bazzo, MD, FAAFP

La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS

North County #1: Arlene J. Morales, MD

North County #2: Christopher M. Bergeron, MD, FACS

North County #3: Nina Chaya, MD

South Bay #1: Paul J. Manos, DO

South Bay #2: Latisa S. Carson, MD

AT–LARGE DIRECTORS

#1: Rakesh R. Patel, MD, FAAFP, MBA (Board Representative to the Executive Committee)

#2: Kelly C. Motadel, MD, MPH

#3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD

#5: Daniel Klaristenfeld, MD

#6: Alexander K. Quick, MD

#7: Karl E. Steinberg, MD, FAAFP

#8: Alejandra Postlethwaite, MD

ADDITIONAL VOTING DIRECTORS

Young Physician: Emily A. Nagler, MD

Resident: Alexandra O. Kursinskis, MD

Retired Physician: Mitsuo Tomita, MD

Medical Student: Jesse Garcia

CMA OFFICERS AND TRUSTEES

Immediate Past President: Robert E. Wailes, MD

Trustee: William T–C Tseng, MD, MPH

Trustee: Sergio R. Flores, MD

Trustee: Timothy A. Murphy, MD

AMA DELEGATES AND ALTERNATE DELEGATES

District I: Mihir Y. Parikh, MD

District I Alternate: William T–C Tseng, MD, MPH

At–Large: Albert Ray, MD

At–Large: Robert E. Hertzka, MD

At–Large: Theodore M. Mazer, MD

At–Large: Kyle P. Edmonds, MD

At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

At–Large: David E.J. Bazzo, MD, FAAFP

At–Large: Sergio R. Flores, MD

At–Large Alternate: Bing Pao, MD

CMA DELEGATES

District I: Steven L.W. Chen, MD, FACS, MBA

District I: Franklin M. Martin, MD, FACS

District I: Eric L. Rafla-Yuan, MD

District I: Peter O. Raudaskoski, MD

District I: Ran Regev, MD

District I: Kosala Samarasinghe, MD

District I: Thomas J. Savides, MD

District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM

District I: Mark W. Sornson, MD

District I: Wynnshang (Wayne) C. Sun, MD

District I: Patrick A. Tellez, MD, MHSA, MPH

District I: Randy J. Young, MD

RFS Delegate: David J. Savage, MD

FEATURES

4 Together We Rise Gala

By Adama Dyoniziak

6 Nick Yphantides, MD, MPH, SDCMS President

2023 Gala Speech

DEPARTMENTS

2 Briefly Noted: Gun Violence • Medi-Cal Funding

11 American Medical Association’s Annual Meeting Installs Historic President and Debates Policy

By Kyle P. Edmonds, MD, FAAHPM

12 X-ing the X Waiver: Now All Physicians Can Treat Opioid Use Disorder By Roneet Lev, MD, FACEP

14

Xylazine Information for Healthcare Professionals

By San Diego County Substance Use and Overdose Prevention Taskforce

16

Advocates Call for 911 Changes. Police Have Mixed Feelings

By Molly Castle Work

18

How Loss Helps Enrich Each Day of Our Lives

By Helane Fronek, MD, FACP, FASVLM, FAMWA

19

The Magical Power of Sharing

By Adama Dyoniziak

16

4

20

Classifieds

AMA Adopts Policies to Help Curb the Public Health Crisis of Firearm Violence

THE AMERICAN MEDICAL ASSOCIATION (AMA) House of Delegates — the association’s policy-making body — adopted a number of new policies to address the public health crisis of firearm violence.

The policies adopted by the AMA House of Delegates include:

Strengthening Background Checks and Preventing Sales of Multiple Firearms to Same Purchaser Within Five Days

Under this new policy, AMA will advocate for federal and state policies that prevent inheriting, gifting, or transferring ownership of firearms without adhering to all federal and state requirements for background checks, waiting periods, and licensure requirements. AMA will also advocate for federal and state policies to prevent the sale of multiple firearms to the same purchaser within five business days and to implement background checks for ammunition purchases.

“As mass shootings in the U.S. continue at an alarming rate, it is critical that we further strengthen policies aimed at preventing firearm violence,” said AMA Immediate Past President Jack Resneck Jr., MD, a San Francisco dermatologist. “No individual should be able to purchase an arsenal of firearms in a short period of time or buy ammunition without a background check. We will continue to advocate for laws and policies that reduce the risk of firearm violence and keep our communities safe.”

Supporting Medical Professionals in Utilizing Extreme Risk Protection Orders to Prevent Firearm Violence Among High-Risk Patients

Currently, more than 20 states have enacted extreme risk protection order (ERPO) laws that allow law enforcement, family or

household members, and/or intimate partners to petition the court to temporarily remove firearms from high-risk individuals through due process. Few jurisdictions include medical professionals as parties who can initiate ERPOs. Given that, AMA adopted policy aimed at including medical professionals as parties who are able to ask a court to prevent someone at imminent risk of harm to themselves or others from purchasing or possessing firearms when there is a high or imminent risk for violence.

“Physicians are encouraged to ask patients at risk of firearm injury about access to firearms during routine patient visits,” said Dr. Resneck. “Allowing physicians to petition the courts when they encounter a patient at risk of firearm violence is necessary and could help prevent further firearm-related tragedies.”

Calling on Social Media Companies to Remove Posts Glorifying Firearm Violence

Delegates also adopted policy aimed at helping curb the proliferation of social media posts that promote firearm violence. Under the new policy, AMA will call on all social media sites to vigorously and aggressively remove posts that contain videos, photographs, and written online comments encouraging and glorifying the use of firearms.

To help end the ongoing and devastating effects of firearm violence in the U.S., AMA also strongly recommends that social media sites continuously update and monitor their algorithms to detect and eliminate any information that discusses and displays firearms and firearm violence in a way that encourages viewers to act violently.

“Misinformation and disinformation continue to spread through social media largely unchecked,” said Dr. Resneck. “With more than 48,000 Americans dying and tens of thousands more seriously injured from firearms every year, we can’t sit by while firearm violence is glorified through social media sites. We implore social media sites to take immediate action to limit these dangerous posts — people’s lives depend on it.”

Historic Budget Law Renews MCO Tax and Expands MediCal Patient Access to Care

THE CALIFORNIA LEGISLATURE passed, and Gov. Newsom signed, the 2023–24 budget, which renews the state’s managed care organization (MCO) tax and provides the largest Medi-Cal rate increase in California history — ensuring that millions of Californians have greater access to affordable, high-quality, lifesaving healthcare.

“The state budget approved by the legislature today represents a historic investment in California’s healthcare system that will help us achieve justice and equity for the more than 14 million Californians who rely on Medi-Cal for their healthcare,” said California Medical Association (CMA) President Donaldo Hernandez, MD. “Physicians across California applaud the legislature for their bipartisan support for legislation to reinstate the MCO tax and use the funding to help fulfil Medi-Cal’s promise of access to care.”

CMA and other members of the Coalition to Protect Access to Care have been working together over the past few months to seize a generational opportunity to make critical and meaningful investments in the Medi-Cal system and shore up our healthcare delivery system.

The coalition’s goal has been to ensure that Medi-Cal enrollees have the same access to care as those with commercial insurance, and that providers can afford to treat a patient population that reflects their communities — without worrying about the financial solvency of their practice. The MCO tax will raise a total of $19.4 billion, with much of it being spent on the state’s healthcare infrastructure.

Starting in 2024, Medi-Cal provider rates will be increased to at least 87.5% of Medicare for primary care, maternity care and non-specialty mental health services. Starting in 2025, the MCO tax will also provide a new infusion of $6 billion for the Medi-Cal program and the healthcare workforce. Specifically, there will be an annual appropriation of $1.38 billion in primary care rate increases, $1.15 billion in specialty care rate increases, $700 million to increase emergency department access (including $200 million for emergency department physicians), at least $500 million for family planning and reproductive healthcare, and $600 million for behavioral health facilities, including increasing inpatient psychiatric beds.

“The state budget makes important investments in primary and specialty care and ensures our hospitals’ emergency departments remain open in times of crisis,” said Dr. Hernandez. “It will also help train hundreds of additional physicians each year so that California is better prepared to meet our growing healthcare needs. We thank the governor and the legislature for their commitment to putting patients first in this state budget, so we are better able to fulfill California’s commitment to healthcare access and equity.”

by Adama Dyoniziak

Public Health and Longevity Science; The Doctor’s Company; Community Health Group; ASMG; Palomar Health; Unio Health Partners; Point Loma Nazarene University; San Ysidro Health; Kaiser Permanente; American Medical Response; Cooperative of American Physicians; TrueCare; Neighborhood Healthcare; and EVS.

This year’s theme was embodied by a phoenix, which symbolizes hope, rebirth, and transformation. The phoenix can heal itself in the transformation of fire and reemerge from its ashes. It is a symbol of strength — like the ability of our PASD patients to endure tough times. Project Access patient Javier G. poignantly expressed his transformation from pain and medical distress to health and renewed life. His story inspires hope for all patients and for each of us who touch their lives.

SDCMS’s outgoing president, Dr. Lasé Ajayi, presented two awards to honor SDCMS physician leadership: the Presidential Citation and the James T. Hay Award.

THIS YEAR, THE SAN DIEGO COUNTY MEDICAL Society and Champions for Health (CFH) joined forces and created a joint gala called “Together We Rise,” which took place at the picturesque San Diego Natural History Museum on May 12. This gala celebrated the outstanding physician leaders of SDCMS, the volunteer physicians and partners of CFH, and welcomed the 153rd president of SDCMS, Dr. Nick Yphantides.

Honored dignitaries who joined us in the festivities included: Consulate General of Mexico Carlos Gonzalez Gutierrez, Senator Toni Atkins, Senator Catherine Blakespear, Assemblymember Laurie Davies, Assemblymember Tasha Boerner, Assemblymember Marie Waldron, San Diego County Board Supervisor Nora Vargas, and San Diego County Board Supervisor Joel Anderson.

A huge thank-you to everyone who supported our joint gala, which helps us raise critical funds for CFH’s flagship program, Project Access San Diego (PASD). We are very grateful to our sponsors for their contribution to an incredible evening: UC San Diego’s Herbert Wersheim School of

 President’s Award: The Vaccinate ALL 58 Campaign launched in December 2020 to raise awareness about the safety and effectiveness of COVID vaccines. With a focus on people most impacted by the virus, the campaign partners with trusted messengers, including CFH, to educate San Diegans on harm reduction, facilitate vaccine-appointment assistance, and strategize how to reach priority populations.

 Partner of the Year: Cross Border Xpress partnered with CFH and Ventanilla de Salud to launch two COVID-19 Stations, one for rapid testing and one for CFH to administer COVID vaccines. The high volume of international passenger flow at the CBX terminal makes it a great location to reach and engage with community members. To date, more than 15 thousand passengers have been tested, and more than 14,000 COVID and flu vaccines have been administered.

 Medical Group of the Year: Coastal Gastroenterology physicians Dr. Robert Goldklang, Dr. Adrienne LaJoie, and Dr. Steven DiLauro have provided over 90 pro bono consultations and procedures since 2010. Together this volunteer trio, with the staff and medical team of Coastal Gastroenterology, know how vital it is for vulnerable patients in great need to receive specialty care. Their synergy transforms patients’ lives.

James T. Hay Award: Dr. David Bazzo of UCSD Health is a well-respected leader in San Diego’s medical community. Dr. Bazzo has repeatedly been named a Top Doctor in both family medicine and sports medicine in San Diego Magazine’s “Physicians of Exceptional Excellence” annual survey, serves as a distinguished professor at UC San Diego School of Medicine, was the first UC San Diego Health physician to serve as president of the San Diego County Medical Society, and has been one of California’s leading advocates for elevating physician wellness as a major priority in our healthcare system. 

 Presidential Citation: Dr Melissa Campos of San Ysidro Health is the past president of the San Diego Academy of Family Physicians (SDAFP) and faculty member for the Scripps Family Medicine Residency Program. Her outpatient clinical work is at San Ysidro Health, where she is passionate about working with the South Bay community in San Diego. She encourages the development of family medicine physicians who choose to work with the underserved, and has focused her career on empowering youth and mentorship.

 Physician of the Year: Dr. Michael Ammar is a volunteer retinal ophthalmologist with PASD since 2021. He treats his patients with warmheartedness, dedication, and compassion. Dr. Ammar believes in helping others without the expectation of anything in return; and that we should work hard to build a future that is a better world than today.

 Champions of the Year: Imaging Healthcare Specialists, a PASD partner since 2009, has committed to providing imaging services to 120 patients per year. Many patients need imaging before a consultation or surgery so without IHS, Project Access staff would struggle to move cases forward. IHS is a vital resource for Project Access patients.

Adama Dyoniziak is the executive director of Champions for Health.

Nick Yphantides, MD, MPH, SDCMS President

2023 Gala Speech

THANK YOU SO MUCH DR. BOB HERTZKA FOR telling part of my life story!

Much love and appreciation to Paul Hegyi and Jen Ohmstede for all your guidance and staff support.

Congrats and thanks to Adama Dyoniziak for a fantastic evening!

Finally, congrats and many thanks to Dr. Lasé Ajayi for her impactful year of leadership as president of our society! I plan on carrying on and championing many of your priorities!

What a night! Very special to me that tonight is the first time we have combined Medical Society and Champions Galas! I have been so very blessed to spend my career focused on those who need it the most. I am thankful to say that in all the years taking care of patients never once have I seen a patient with health insurance here in San Diego County.

It is almost embarrassing to admit that for several years I was reluctant to even join the medical society as it was too physician-centric. I recall discussing extensively with Dr. Hay who can attest to that reality and I so appreciate how receptive he was to my desire to bring a much more patientcentric and community-focused flavor to the society.

As your new president, these are the three areas of focus and priority for me over the coming year.

1. The wellbeing of our community and our patients. We have to work hard to restore the trust and confidence in our profession.

2. Focusing on our future colleagues. Upstream investment of time and attention. I call it being a relational venture capitalist. Investing in the future physician workforce with the return on investment being the impact on the most disadvantaged in our region.

3. Vulnerable and authentic care for each other as clinicians. Pursuing and prioritizing our personal wellness and emotional wellbeing. October 2020 through March of 2021 was a brutal personal season of crisis and emotional suffering for me personally. I am not ashamed to admit it and am passionate about destigmatizing behavioral health challenges within our profession. One of my favorite authors, C.S. Lewis, once said, “The beginning of true friendship is when one says to another, ‘What? You too? I thought I was the only one.’”

As such, we need more fellowship and time to bond and deepen our camaraderie. I’d like to announce that on Saturday, September 2, 2023, we will have the first ever “Physician Appreciation Night” with the San Diego Padres when they take on the San Francisco Giants. More details and communications to follow.

While we are on the subject of appreciation, I’d like to ask for the liberty to introduce you to the precious people in my life that I appreciate and cherish the most.

Mom. (Happy Mothers Day!) My siblings Paul, John, Phil, and Pauline. Proverbs 17:17 says, “A friend loves at all times but a brother is born for a time of adversity.” Tim Stripe is such a friend, and he and his wife Janean are here this evening. I also would like to call my former colleague at the county, Dr. Michael Krelstein, who was a friend and a lifesaver during my darkest days in the midst of the COVID pandemic.

The most important gift in my life is the honor and delight to be called Daddy. Veronique and Zoe are the delights of my life. My angels without wings.

Thank you all so very much.

My personal thanks again to Adama and her entire staff for putting this all together. And much appreciation to all those who we recognized tonight diligently serving the patients in our community who need it the most.

A repeat special thank-you to the Medical Society staff of Paul, Jen, and Brandon. Congrats galore to Lasé. Thanks again, Bob, for your love and support.

A reminder: silent auction. You may have won! So please check the table on the way out.

I just want to end on a symbolic and personal note. During the darkest days of my crisis, there was a song that I listened to over and over that was such an encouragement to me. It’s

called “The Blessing,” and if you have never heard it I would encourage you to give it a listen. To make it easy for you, a couple days ago I posted it on my Facebook page. I want to leave you with the lyrics which are straight out of the Old Testament from the book of Numbers chapter 6 verses 24–26: “May the Lord bless you and protect you. May the Lord smile on you and be gracious to you. May the Lord show you his favor and give you his peace.”

May you all be blessed beyond belief! Good night and thanks upon thanks!

American Medical Association’s Annual Meeting Installs Historic President and Debates Policy

By Kyle P. Edmonds, MD, FAAHPM

THE AMA’S ANNUAL MEETING OCCURS EVERY year in downtown Chicago and represents one of two yearly opportunities to nudge the AMA in new directions. As the deliberative body of the organization continues to emerge into this new phase of the COVID-19 pandemic, AMA Annual 2023 felt more normal than it has in many years. There was policy to be debated, candidates for office to evaluate, an AMA president from California completing his term, and a historic new president to install in office.

While our kids were downstairs at Camp AMA, the Young Physician Section heard from San Diego pediatrician and immediate past president of SDCMS, Dr. Toluwalasé Ajayi, about the efforts the AMA has taken in the past year to combat intrusion into the practice of medicine, whether that is through obstructive prior authorization policies, careerlimiting non-compete clauses, or governmental interference in gender-affirming medicine and abortion services. She also updated us on the creation of the AMA’s Truth, Reconciliation, Healing, and Transformation Taskforce as an advisory body to the board and as part of the AMA’s strategic plan to embed racial justice and health equity within the organization and across healthcare.

California dermatologist and outgoing AMA president Dr. Jack Resneck Jr. reminded us at the opening of the meeting, “We are more resolute in our work because of the challenges and existential threats to our profession and to our patients. Even when there are temporary setbacks, our common cause is to speak out for, and to advance our flame, our ethical values, and our common purpose — that is what keeps us going.”

The business of the meeting was typically broad and centered around the AMA’s Recovery Plan for America’s Physicians: fighting scope creep, reducing physician burnout, tackling prior authorization, reforming Medicare payment, and supporting telehealth. The delegates broke into a sustained standing ovation at the passage of policy to further amplify the AMA’s efforts to reform our broken Medicare physician payment system and followed that up in short order with new policy on protecting medication access and physician-patient relationships from government intrusion, prior authorization reform, strengthening physician-led

teams, and the critical role of race-conscious admission practices in ensuring a physician workforce

that looks like the U.S. We also took firm positions on protecting the right of pregnant people to reproductive healthcare and abortion services as well as maintaining the rights and safety of our transgender patients and colleagues.

As the meeting came to a close, we installed Dr. Jesse Ehrenfeld of Wisconsin as the AMA’s first openly gay president. Dr. Ehrenfeld is a phenomenal leader, a combat veteran, and a friend of mine for 17 years. He took his oath of office with

his husband, Judd Taback, and two children on the dais. Reflecting on his son’s difficult start to life in a Chicago NICU, he said, “Watching my son cling to life, I was struck by the painful reality that, even though I was a physician and now, a father, neither I, nor my husband, could donate blood simply because we are gay. Discriminatory policies — policies rooted in stigma, not science — barred us from doing the most humane of acts, donating our blood.” Later he continued, “Just recently, the FDA, thanks in large part to a decade of advocacy by our AMA and others, rescinded some of these discriminatory practices, making it possible, for the first time, for my husband and I to give someone else’s child a much-needed blood transfusion. This kind of advocacy is why I am so proud to lead our AMA at this moment.”

Dr. Edmonds is director and section chief of the UC San Diego Palliative Care Program and has been active at the AMA since he was a first-year medical student. He is a delegate to the AMA House of Delegates from California, and a representative to the AMA Young Physician Section from the American Academy of Hospice & Palliative Medicine. He also discloses that he’s not impartial when it comes to AMA Trustee Dr. Lasé Ajayi, since the two have been married for many years.

X-ing the X Waiver

Now All Physicians Can Treat Opioid Use Disorder

By Roneet Lev, MD, FACEP

as asthma or diabetes. Treating addiction is rewarding. Using medications to treat opioid use disorder reduces the death rate by 50% or more and has excellent retention rates of 50% at one year.

No patient should ever suffer from opioid withdrawal. We have a very effective treatment with buprenorphine. A general guide is a COWS (Clinical Opiate Withdrawal Scale) of 8, give 8mg of Suboxone.

Physicians of most specialties should be able to start and maintain patients on medication for OUD. You can undoubtedly refill medicines for patients who are in treatment.

There are three excellent resources to start your rewarding experience treating addiction, especially OUD:

• California Bridge: Bridgetotreatment.org

Tools on this website include Buprenorphine Quick Start, Buprenorphine Patient Materials, and much more.

• National Clinical Consultation Center (NCCC): California Substance Use Line (844) 326-2626

The California Substance Use Line is a free 24/7 teleconsultation for California clinicians.

MEDICAL PROVIDERS WITH A DEA LICENSE COULD prescribe opioids but were not allowed to prescribe treatment for opioid addiction without additional government hoops. That stipulation was known as the “X waiver.” Now the X waiver barrier has finally been removed by Congress.

In short, the X waiver is no longer required to prescribe buprenorphine for opioid use disorder (OUD) treatment. Additionally, there are no caps or limitations on the number of patients a prescriber can treat simultaneously.

That means that every DEA-licensed physician can provide opioid addiction treatment. It is a move in the right direction for integrating physical health, mental health, and substance use disorder (SUD).

There is a learning curve to everything. But you can do this. You learned many new things in your medical career, and treating opioid use disorder is rewarding.

Our San Diego Medical Examiner reported 2.25–2.5 deaths a day from fentanyl for the past two years. Fentanyl is the public health crisis of our time. The medical community needs to rise to this crisis like we did for COVID.

This is an opportunity to point out that substance use disorder is a chronic, relapsing, yet treatable brain disease. Addiction relapse rates are like other chronic diseases such

UC San Francisco runs this NCCC and is familiar to many clinicians who used their service for HIV Post Exposure Prophylaxis. They offer similar services to assist with alcohol and drug treatment recommendations. Call them if you are new to MAT, need advice on a specific patient, or have a complex addiction case.

• SAMHSA Buprenorphine Quick Start: samhsa.gov/ sites/default/files/quick-start-guide.pdf

The Substance Abuse and Mental Health Services Administration has a quick-start and pocket guide for buprenorphine.

Dr. Lev was the first chief medical officer of the White House Office of National Drug Control Policy, ONDCP. She is a nationally acclaimed medical expert and speaker who continues to treat patients in the emergency department.

In 2012, she established and chaired the San Diego Prescription Drug Abuse Medical Task Force, the first of its kind in California that integrated physicians of various specialties along with hospitals, law enforcement, hospital administration, treatment programs and public health for the purpose of decreasing deaths and mortality from prescription drugs. Her program on Safe Prescribing in the emergency department won the 2014 National Association of Counties award. The California U.S. Attorney’s office nominated her for the White House Champion of Change Award.

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XYLAZINE Information for Healthcare Professionals

XYLAZINE Information for Healthcare Professionals

What is xylazine?

What is xylazine?

Xylazine is a veterinary tranquilizer, (a nonopioid), which is sometimes mixed with fentanyl and other illicit drugs. Xylazine is an analog of clonidine acting as an alpha-2 agonist. It is FDAapproved as a sedative in veterinary medicine but is not approved for human use. The drug is not scheduled under the Controlled Substances Act.

Xylazine is a veterinary tranquilizer, (a nonopioid), which is sometimes mixed with fentanyl and other illicit drugs. Xylazine is an analog of clonidine acting as an alpha-2 agonist. It is FDAapproved as a sedative in veterinary medicine but is not approved for human use. The drug is not scheduled under the Controlled Substances Act.

Why do people use xylazine?

Why do people use xylazine?

Illicit xylazine is also known as Tranq. It may be found as an adulterant in fentanyl, heroin, cocaine, and methamphetamines. People often use the drugs that are available to them in their local supply. Similar to fentanyl, many people did not know they were being exposed to it in their supply. Some people also report purposely using xylazine-containing fentanyl to lengthen its euphoric effects.

Illicit xylazine is also known as Tranq. It may be found as an adulterant in fentanyl, heroin, cocaine, and methamphetamines. People often use the drugs that are available to them in their local supply. Similar to fentanyl, many people did not know they were being exposed to it in their supply. Some people also report purposely using xylazine-containing fentanyl to lengthen its euphoric effects.

Has xylazine been detected in San Diego County?

Has xylazine been detected in San Diego County?

The San Diego Medical Examiner’s Office reported one xylazine death in 2020 and no deaths in 2021. Previously, xylazine was not routinely tested for unless expanded testing was indicated. In late April 2023, xylazine testing was initiated in all routine post-mortem screenings, and of more than 1,000 screened deaths occurring between November 2022 and May 2023, six were positive for xylazine. Of the six xylazine cases, all were also positive for other drugs, including fentanyl

The San Diego Medical Examiner’s Office reported one xylazine death in 2020 and no deaths in 2021. Previously, xylazine was not routinely tested for unless expanded testing was indicated. In late April 2023, xylazine testing was initiated in all routine post-mortem screenings, and of more than 1,000 screened deaths occurring between November 2022 and May 2023, six were positive for xylazine. Of the six xylazine cases, all were also positive for other drugs, including fentanyl

and methamphetamine. The San Diego Sheriff’s Department Crime Lab includes xylazine testing in all drug seizure cases and has confirmed thirty-six samples where illicit drugs contained xylazine from 2021 through the first quarter of 2023. Although xylazine does not appear to be as prevalent in San Diego County as in some other jurisdictions, residents should be aware of the risks associated with xylazine and be proactive in mitigating them, particularly because national trends indicate its increasing presence in overdose deaths and the illicit drug supply.

and methamphetamine. The San Diego Sheriff’s Department Crime Lab includes xylazine testing in all drug seizure cases and has confirmed thirty-six samples where illicit drugs contained xylazine from 2021 through the first quarter of 2023. Although xylazine does not appear to be as prevalent in San Diego County as in some other jurisdictions, residents should be aware of the risks associated with xylazine and be proactive in mitigating them, particularly because national trends indicate its increasing presence in overdose deaths and the illicit drug supply.

How do you test for xylazine?

How do you test for xylazine?

As of May 2023, there are no FDA-approved rapid tests checking for xylazine in patients in a hospital or clinic setting. Testing may be available as a send out laboratory specimen to a specialized lab that uses gas chromatography/mass spectrometry. Xylazine test strips are commercially available by BTNX for testing drug products.

As of May 2023, there are no FDA-approved rapid tests checking for xylazine in patients in a hospital or clinic setting. Testing may be available as a send out laboratory specimen to a specialized lab that uses gas chromatography/mass spectrometry. Xylazine test strips are commercially available by BTNX for testing drug products.

What are the signs and symptoms of a xylazine-involved overdose?

What are the signs and symptoms of a xylazine-involved overdose?

The main effect of xylazine is heavy sedation, so the person who has overdosed will likely be unresponsive. When xylazine is found in combination with fentanyl or other opioids, the signs and symptoms can include blue or greyish skin and slowed breathing and heart rate.

The main effect of xylazine is heavy sedation, so the person who has overdosed will likely be unresponsive. When xylazine is found in combination with fentanyl or other opioids, the signs and symptoms can include blue or greyish skin and slowed breathing and heart rate.

FDA WARNING

FDA WARNING

The United States Food and Drug Administration (FDA) issued a letter to stakeholders providing clinical information about the risks of severe, necrotic skin ulcerations from repeated xylazine exposure, possible withdrawal symptoms, and xylazine’s interference with successful treatment of opioid overdoses. View the letter: www.fda.gov/media/162981/download

The United States Food and Drug Administration (FDA) issued a letter to stakeholders providing clinical information about the risks of severe, necrotic skin ulcerations from repeated xylazine exposure, possible withdrawal symptoms, and xylazine’s interference with successful treatment of opioid overdoses. View the letter: www.fda.gov/media/162981/download

It is not known at this time whether the xylazine is illicitly produced (unapproved) or

It is not known at this time whether the xylazine is illicitly produced (unapproved) or

diverted from the animal drug supply. FDA is continuing to investigate the source of xylazine in the illicit drug supply and will provide an update when new information is available.

diverted from the animal drug supply. FDA is continuing to investigate the source of xylazine in the illicit drug supply and will provide an update when new information is available.

FDA encourages health care professionals and patients to report adverse events in humans associated with possible illicit xylazine exposure to FDA’s MedWatch Adverse Event Reporting program. Complete and submit the report online at www.fda.gov/medwatch/report.htm; or download and complete the form, then submit it via fax at 1-800-FDA-0178.

FDA encourages health care professionals and patients to report adverse events in humans associated with possible illicit xylazine exposure to FDA’s MedWatch Adverse Event Reporting program. Complete and submit the report online at www.fda.gov/medwatch/report.htm; or download and complete the form, then submit it via fax at 1-800-FDA-0178.

XYLAZINE Information for Healthcare Professionals

XYLAZINE Information for Healthcare Professionals

Does naloxone reverse xylazine-involved overdoses?

Does naloxone reverse xylazine-involved overdoses?

No, xylazine is not an opioid, so naloxone will not reverse a xylazine overdose However, because xylazine is frequently found in combination with opioids, including fentanyl, naloxone should still be administered whenever an opioidinvolved overdose is suspected. Naloxone will reverse the effects of the opioids, and therefore may improve the patient’s respiratory status.

No, xylazine is not an opioid, so naloxone will not reverse a xylazine overdose However, because xylazine is frequently found in combination with opioids, including fentanyl, naloxone should still be administered whenever an opioidinvolved overdose is suspected. Naloxone will reverse the effects of the opioids, and therefore may improve the patient’s respiratory status.

How do you manage xylazine toxicity?

How do you manage xylazine toxicity?

If clinical presentation is consistent with xylazine toxicity, it is recommended to treat the patient with supportive care.

If clinical presentation is consistent with xylazine toxicity, it is recommended to treat the patient with supportive care.

How long does the effect of xylazine last?

How long does the effect of xylazine last?

The onset of xylazine is rapid, within a few minutes, and the duration can last up to four hours. However, pharmacology is based on injected control doses in animal studies. In human pharmacology, duration depends on the dose, modality of ingestion, individual metabolism, and whether co-ingestion with opioids exist.

The onset of xylazine is rapid, within a few minutes, and the duration can last up to four hours. However, pharmacology is based on injected control doses in animal studies. In human pharmacology, duration depends on the dose, modality of ingestion, individual metabolism, and whether co-ingestion with opioids exist.

What are the symptoms of xylazine withdrawal?

What are the symptoms of xylazine withdrawal?

Xylazine withdrawal is not a well-defined syndrome and may include anxiety, irritability, and restlessness. Severe hypertension is also possible.

Xylazine withdrawal is not a well-defined syndrome and may include anxiety, irritability, and restlessness. Severe hypertension is also possible.

Does xylazine cause skin ulcers?

Does xylazine cause skin ulcers?

Although research has yet to definitively prove that xylazine causes skin ulcers, there appears to be an association between the two. People who regularly use xylazine often have severe skin ulcers and abscesses. Hospital systems throughout the US have reported an increase in skin and soft tissue infections. These wounds are presenting atypically, often all over the body (away from the site of injection) and appear to worsen more quickly than other skin infections. These presentations may be related to vasoconstrictor properties of xylazine. These significant wounds have been reported in individuals using xylazine even when the drug has not been injected.

Although research has yet to definitively prove that xylazine causes skin ulcers, there appears to be an association between the two. People who regularly use xylazine often have severe skin ulcers and abscesses. Hospital systems throughout the US have reported an increase in skin and soft tissue infections. These wounds are presenting atypically, often all over the body (away from the site of injection) and appear to worsen more quickly than other skin infections. These presentations may be related to vasoconstrictor properties of xylazine. These significant wounds have been reported in individuals using xylazine even when the drug has not been injected.

What wounds are associated with xylazine?

What wounds are associated with xylazine?

People who inject drugs containing xylazine may develop severe skin wounds and patches of dead and rotting tissue that easily become infected and, if left untreated, may lead to amputation. These wounds can develop in areas of the body away from the injection site and may become life-threatening. Wounds can be deep and should be evaluated for possible necrotizing fasciitis and osteomyelitis.

People who inject drugs containing xylazine may develop severe skin wounds and patches of dead and rotting tissue that easily become infected and, if left untreated, may lead to amputation. These wounds can develop in areas of the body away from the injection site and may become life-threatening. Wounds can be deep and should be evaluated for possible necrotizing fasciitis and osteomyelitis.

How do you dress an ulcer wound?

How do you dress an ulcer wound?

Xylazine wounds should be evaluated in a similar fashion to other drug-associated wounds including possible deep infection, necrotizing fasciitis, osteomyelitis, and sepsis. After initial evaluation and determination of whether surgical intervention is needed, remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing.

Xylazine wounds should be evaluated in a similar fashion to other drug-associated wounds including possible deep infection, necrotizing fasciitis, osteomyelitis, and sepsis. After initial evaluation and determination of whether surgical intervention is needed, remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing.

Resources for Healthcare Professionals

Resources for Healthcare Professionals

National Institute on Drug Abuse (NIDA) nida.nih.gov/research-topics/xylazine

National Institute on Drug Abuse (NIDA) nida.nih.gov/research-topics/xylazine

For information regarding withdrawal management and treatment options, the California Substance Use Line is available 24/7 to California clinicians. (844)326-2626

For information regarding withdrawal management and treatment options, the California Substance Use Line is available 24/7 to California clinicians. (844)326-2626

Harm Reduction Services

Harm Reduction Services

The primary goal of harm reduction is to save lives and protect the health of people who use drugs by linking them with resources and services. National Harm Reduction Technical Assistance Center – harmreductionhelp.cdc.gov

The primary goal of harm reduction is to save lives and protect the health of people who use drugs by linking them with resources and services. National Harm Reduction Technical Assistance Center – harmreductionhelp.cdc.gov

California Bridge – www.CABridge.org

California Bridge – www.CABridge.org

San Diego County Access & Crisis Line 1-888-724-7240

San Diego County Access & Crisis Line 1-888-724-7240

Naloxone and Fentanyl Test Strips Resources Call 2-1-1

Naloxone and Fentanyl Test Strips Resources Call 2-1-1

Advocates Call for 911 Changes. Police Have Mixed Feelings

By Molly Castle Work

A MOUNTAIN OF EVIDENCE SHOWS POLICE OFTEN fail to respond properly to people experiencing a mental health crisis. It can lead to avoidable deaths and criminalization of mental illness, especially among people of color.

A poll commissioned by Public Health Advocates, a Davis-based health policy nonprofit, showed that more than two-thirds of California voters want behavioral health professionals to be part of the emergency response in non-

life-threatening situations. Among seven types of situations potentially warranting emergency response, voters think law enforcement agencies are least equipped to respond to calls about mental health crises and people who are unhoused, according to the May 24 poll.

“Police response has become the oversized bandaid for something the bandaid was never designed to cover or heal,” said Ryan McClinton, who manages Public Health Advocates’ First Response Transformation Campaign.

His group and likeminded advocates in California are stepping up a campaign to overhaul the state’s 911 system so more mental health professionals and others with specialized training handle many emergencies, rather than the police.

Law enforcement officials agree that 911 response merits a more nuanced approach. But powerful police unions are against proposals that might reduce their

control over 911 operations, and the budget and staff that go with them. Police representatives contacted said they favored alternatives that would supplement the current system rather than supplant it, and that would keep overall responsibility for 911 with police departments.

“Our 911 dispatchers do an amazing job and are the perfect people to handle those in crisis,” said Tim Davis, president of the Sacramento Police Officers Association, a union. “It is imperative that 911 remain under the direction of the police department, as the majority of the calls they receive are for police services.”

McClinton, however, said emergency response systems are outdated and in need of transformation. In many California counties, change is already underway. Forty-one of the state’s 58 counties have some form of mobile crisis services in which mental health workers go out and address crisis needs in the community, according to a survey conducted by the County Behavioral Health Directors Association of California.

Michelle Cabrera, executive director of CBHDA, said that by next year all California counties will have mobile crisis services up and running.

Established in 1968, 911 was designed for reporting fires. However, it quickly became an all-purpose sys-

tem for routing a much broader set of calls to police.

Californians now make more than 25 million 911 calls annually. Nationally, as many as 15% are for behavioral health emergencies, according to a 2021 study in the journal Psychiatric Services.

Andrea Rivera, a legislative health advocate, said 911 centers today are inundated with calls that aren’t necessarily emergencies — an influx the system wasn’t built to handle.

“911 has become a catchall,” said Rivera, who works for the California Pan-Ethnic Health Network. “While it might be unfair to law enforcement, which doesn’t have the capacity or training, it’s particularly unfair for the community members that don’t feel like they have someone to turn to.”

Alternative approaches vary widely across the state. Santa Clara County, for example, has five mobile response teams that can respond to 911 calls, and can also be deployed by dispatchers at 988, the national Suicide and Crisis Lifeline. Some teams are made up of clinicians and other trained professionals who can provide peer support. Some respond alongside police, while others arrive wearing plainclothes in a non-police vehicle.

Sandra Hernandez, a division director of Behavioral Health Services in Santa Clara County, said the program is in its infancy but has been effective so far. One surprising takeaway she noted was how much community members appreciated being able to ask for help without emergency vehicles arriving at their doorstep and alerting nosy neighbors to a moment of crisis.

Hernandez recalled one letter her team received from a grateful resident: “My neighbors didn’t even know. They thought I had company.”

Cities in Oregon, New Mexico, and Colorado have similar programs.

Advocates point to cases like that of Jaime Naranjo, a Sacramento County resident who was shot and killed by police last year at his home. Naranjo’s wife, Elisa Naranjo, said her husband was suicidal and had been experiencing delusions and carrying a machete when she called 911 for help.

Sacramento has a Mobile Crisis Support Team, but it’s not 24/7 and Elisa called 911 outside its hours of operation. The Sacramento County Sheriff’s Office said that when police arrived the deputy told Naranjo to drop the weapon, but he did not comply. That, the Sheriff’s Office said, is when Naranjo advanced on the deputy, who shot and killed him.

In California, proposed legislation would make alternative response a statewide requirement. State Sen. Aisha Wahab’s SB 402, which is championed by Public Health Advocates, would require 911 service centers to dispatch professionals other than armed police officers for calls related to mental health or homelessness.

This approach is akin to the role 988 was meant to fill, Wahab said, but low awareness of the 988 number has been a barrier to effectiveness.

Wahab introduced an alternative response program three years ago in Hayward, while on its City Council, and said its success inspired her to draft the legislation. She said the bill, whose fate won’t be decided until next year, is a priority for her but acknowledged it would be complicated to enact changes statewide.

Police union representatives said they supported the idea of alternative response in principle.

“Our members are not mental health professionals,” said Alexa Pratt, the communications director for the Association of Orange County Deputy Sheriffs. “We agree that law enforcement should not be the lead addressing mental health calls but should be there to assist in these programs.”

Tom Saggau, a San Jose Police Officers’ Association spokesperson, referenced a pilot program in San Jose of which police were initially skeptical, until they saw how sharing the burden of emergency call response eased their workload. The program has grown sixfold in eight years.

Saggau, who also represents the Los Angeles Police Protective League, a union, said Los Angeles has drafted a list of 28 types of calls that could be diverted to other initial responders and don’t require a police presence.

Still, police departments are protective of their control over 911 and associated personnel and funding.

Saggau criticized proposals to restructure 911 as outgrowths of the “defund the police” movement and voiced frustration that some advocates think supporting alternative response requires a redistribution of police budgets.

The push to defund the police, which gained international momentum after George Floyd’s murder in 2020, refers to reallocating funding away from police departments to other government agencies that support social services.

“It’s not an either-or,” Saggau said. “You can have a fully staffed, robust police department and you can also have a robust alternative response model.”

Wahab believes it’s critical to ensure all cities and counties have clinicians and other unarmed emergency responders on hand.

“It’s very simple,” Wahab said. “You save lives by having the appropriate response to a crisis.”

Molly Castle Work is a correspondent for Kaiser Health News and covers healthcare in California. This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

How Loss Helps Enrich Each Day of Our Lives

By Helane Fronek, MD, FACP, FASVLM, FAMWA

resources did you lean on for support? While each loss is unique, and some more profound than others, past experiences offer faith that we have the capacity to deal with whatever the future holds. While we can’t predict our losses, one sure thing is that we will continue to face them throughout our lives.

ZEN HOSPICE CHAPLAIN FRANK OSTASESKI IS often asked how he helps people approach loss and death. He suggests that how we deal with endings in our lives tells us a lot about how we will approach our own or others’ deaths. On leaving a party, do we take time to say goodbye, or do we sneak out the back? Do we leave quietly so we don’t call attention to ourselves, or because goodbyes feel uncomfortable? I like to say goodbye to those with whom I’ve spoken — to tell them how much I appreciated our conversation and the connection we had.

Frank wonders why we often wait to the end of our lives before telling people how much they mean to us. It’s a good question, and an important reminder.

A common concern adding to our fear of death is that we don’t trust our ability to manage — before or after it occurs. In fact, we have all experienced many losses and endings. What strengths helped you through those times? What

What often remains after a loss is a painful sense of emptiness. Allowing ourselves to feel this emotion, rather than distracting ourselves or pushing the feeling away, is usually the healthiest way forward. The Jewish religion wisely prescribes stages of mourning, starting by providing a community to support and engage mourners in frequent discussion of the person who has passed away. Believing we are the only ones who suffer or pretending that we don’t feel sad makes us feel even more alone.

Knowing we are not alone in our sadness provides a sense of common humanity that can help us recover after any loss or disappointment in life.

And at the end of any-

thing we value, we often feel a sense of clinging. We don’t want it to end. Unfortunately, clinging can prevent us from recognizing what is still there. What resources, people, or opportunities can continue to support us and offer substance to our lives? We may also feel we aren’t enough without the person or experience we’re losing. In fact, most meaningful relationships help us grow and enrich us. What are we grateful to have learned from this relationship or experience that we can now carry forward in our lives?

While the contemplation of loss can seem morbid, the recognition that all people and things are impermanent — a principal tenet of Buddhism — inspires us to live more fully and appreciate what we have. As Stephen Jenkinson writes in Die Wise, our culture breeds a sense of entitlement — we expect to have another day. What if, instead, we woke up with gratitude that we GET to have another day and a sense of wonder about what it might hold for us?

Dr. Fronek is an assistant professor of clinical medicine at UC San Diego School of Medicine and a Certified Physician Development Coach, CPCC, PCC.

The Magical Power of Sharing

By Adama Dyoniziak

FOR SEVEN YEARS, NANCY HAD BEEN battling severe anemia, uncontrolled hemorrhaging, exhaustion, and indescribable pain. She was in the hospital twice for blood transfusions, once with a three-day hospital stay. Nancy lost cleaning jobs in hotels and private homes due to frequent and uncontrolled bleeding and weakness. She was always afraid of leaving her home for too long because she would have an episode while away. Nancy would isolate herself with her children to not risk being embarrassed in public. She had years of feeling anger, frustration, and hopelessness as she dealt with her severe medical condition.

When Nancy was connected to Project Access and Dr. Kimberly Washkowiak, she saw the hope and possibility she had lost. Dr. Washkowiak is an ob-gyn at Scripps Clinic La Jolla. Nancy describes her meetings with the doctor as informative, warm, and assuring.

“My doctor — she is a beautiful human being, she is sweet … I felt her warmth, her appreciation, her concern for me,” Nancy explains.

After an initial consultation and imaging, there was a discussion about the possibility of surgery. “The doctor explained everything so well to me,” Nancy continues. “She explained it would be for my good, she told me the advantages and disadvantages. Of course, I was scared, but she gave me options.”

Dr. Washkowiak adds, “It gives me great pride to volunteer for Project Access. I am so happy to provide patients with relief from their pain, which affects their quality of life so greatly. They wouldn’t have access to medical care otherwise. I would wholeheartedly recommend volunteering because it grounds you and brings you back to why you started in medicine. You can do amazing things for people.”

Nancy happily recalls the surgery day and the days of care afterward. “I felt important, cared for, like a queen when [Dr. W] checked on me,” she says. Nancy says sometimes she cannot believe where she is now. “Now here I am, sharing my story and I would love to have the magical power to share my feelings of being grateful directly to the doctors, to give them my gratitude, to share this feeling I have in my chest because I am alive, I am here … I am here.”

“No one in my family is in medicine — I am the first doctor,” Dr. Washkowiak explains. “Educating women

about their bodies is very rewarding. The best part about being a physician is the long-term relationships developed with patients.” She believes in doing everything in moderation to have balance in life. She is married, has three children, and Zoe, a pit-lab mix who is the gem of the family. Kimberly’s bucket list includes becoming a pilot, seeing the northern lights in Alaska, and learning to play the ukelele in Hawaii.

Since 2008, Project Access has facilitated $27 million in care for 9,600 uninsured patients just like Nancy by providing free

consultations and surgeries — all thanks to the dedication of our volunteer specialty physicians. Share your time and talent: email adama.dyoniziak@championsfh.org or call (858) 300-2780.

Adama Dyoniziak is the executive director of Champions for Health.

Top: Nancy M.

Above: Dr. Kimberly Washkowiak

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PRACTICE ANNOUNCEMENTS

PSYCHIATRIST AVAILABLE! Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.

PHYSICIAN OPPORTUNITIES

INTERNAL MEDICINE PHYSICIAN: FEDERALLY

Qualified Health Center located in San Diego County has an opening for an Internal Medicine Physician. This position reports to the chief medical officer and provides the full scope of primary care services, including diagnosis, treatment, and coordination of care to its patients. The candidate should be board eligible and working toward certification in Internal Medicine. Competitive base salary, CME education, Four weeks paid vacation, year one, 401K plan, No evenings and weekends, Monday through Friday, 8:00 am to 5:00 p.m.

For more information or to apply, please contact Dr. Keith Brady at: uabresearchdoc@yahoo.com.

FAMILY MEDICINE/INTERNAL MEDICINE PHYSI -

CIAN: San Diego Family Care is seeking a Family Medicine/Internal Medicine Physician (MD/DO) at its Linda Vista location to provide outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@ sdfamilycare.org or call us at (858) 810-8700.

MEDICAL CONSULTANT (MD/DO): The County of San Diego is currently accepting applications from qualified candidates for Medical Consultant-Public Health Services. Vacancies are in the Public Health Services, Epidemiology and Immunization Services Branch (EISB) and Tuberculosis (TB) Control and Refugee Health Branch. Salary: $183,747.20–$204,900.80 Annually. An additional 10% for Board Certified Specialty and 15% for relevant Sub-Specialty. For job posting info visit https:// www.governmentjobs.com/careers/sdcounty?keywords =23416202PHS.

MEDICAL DIRECTOR, FULL-TIME: FATHER JOE’S

VILLAGES: Join us in ending homelessness! We are a dynamic team that runs an FQHC. The Medical Director oversees clinical aspects of the primary care, psychiatry, dental and behavioral health. This position will be a mix of clinic and admin time and will have direct reports (Dental Director, Director of Behavioral Health, and frontline primary care/psychiatry providers). Reports to the Chief Medical Officer, who is responsible for all aspects of the clinic. The Medical Director is a counterpart to the Clinic Director (who oversees admin staff, MA/RN team, billing, PSRs, etc.). See FJV Jobs to apply.

SEEKING MEDICAL DIRECTOR: subcontracted position 4-8 hours per month. Responsibilities: Support case conferences, refractory SUD, co‐occurring conditions, specialty populations; Conduct clinical trainings on issues relevant to staff (e.g., documentation, ASAM Criteria, DSM‐5, MAT, WM, co‐occurring conditions); Provide oversight and clinical supervision; Refer co‐occurring conditions; Lead Quality Improvement functions (e.g., Quality Improvement Projects, clinical team meetings, etc.); Attend annually 5 hours of continuing medical education on addiction medicine. Required by contract with San Diego County BHS, position is for a Physician licensed by CA Medical Board or CA Osteopathic Medical Board. Contact Name: Jennifer Ratoff: e-mail: jratoff@secondchanceprogram.org, phone: (619) 839-0950

PSYCHIATRIST SPECIALIST: The County of San Diego is currently accepting applications from qualified candidates. Annual Salary: $258,294.40. Note: An additional 10% is paid for Board Certification, or 15% for Board Certification that includes a subspecialty. Why choose the County? Fully paid malpractice insurance; 13 paid holidays; 13 sick days per year; Vacation: 10 days

(1-4 years of service); 15 days (5-14 years of service; 20 days (15+ years); Defined benefit retirement program; Cafeteria-style health plan with flexible spending; Wellness incentives. Psychiatrist-Specialists perform professional psychiatric work involving the examination, diagnosis, and treatment of specialty forensics, children/adolescents and or geriatric patients. This is the specialty journey level class in the series that requires a fellowship or experience in child and adolescent psychiatry or forensic psychiatry. For more information visit our website at sandiegocounty.gov/hr or select this link to link to go directly to the Psychiatrist Specialist application.

PRIMARY CARE PHYSICIAN: Imperial Valley Family Care Medical Group is looking for Board Certified/Board Eligible Primary Care Physician for their clinics in Brawley and El Centro CA. Salaried/full time position. Please fax CV/salary requirements to Human Resources (760) 355-7731. For details about this and other jobs please go to www.ivfcmg.com

ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN_RESIDENCE)

MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http:// med.ucsd.edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For more information: https://apol-recruit.ucsd.edu/ JPF03179 For help contact: klsantos@health.ucsd.edu

DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@ hotmail.com

INTERNAL MEDICINE PHYSICIAN: Healthcare Medical Group of La Mesa located at 7339 El Cajon Blvd. is looking for a caring, compassionate, and competent physician for providing primary care services. We require well-organized and detail-oriented with excellent written and oral communication skills, and excellent interpersonal skills to provide high-quality care to our patients. We provide a competitive salary, paid time off, health insurance, 401K benefits, etc. We provide plenty of opportunities to refine your clinical competency. Our CEO Dr. Venu Prabaker, who has 30 years of teaching experience as a faculty at multiple universities Including Stanford, UCSD, USC, Midwestern, Western, Samuel Merritt, Mayo, etc., will be providing teaching rounds once a week. You will also get plenty of opportunities to attend other clinical lectures at many of the 4- to 5-star restaurants in San Diego. We also have a weekly one-hour meeting for all the staff for team building and to create a “family atmosphere” to improve productivity and thereby create a win-win situation for all. Visit us at caremd.us.

RADY CHILDREN’S HOSPITAL PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego is seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA

license. Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org.

TUBERCULOSIS CONTROL & REFUGEE HEALTH CHIEF AND MEDICAL DIRECTOR: recruitment is attached and linked here https://www.governmentjobs.com/careers/sdcounty/jobs/3223044/chief-tbcontrol-refugee-health-public-health-medical-officer21412809uth

PUBLIC HEALTH SERVICES MEDICAL CONSULTANT M.D., D.O: Medical Consultant-21416207 | Job Details tab | Career Pages (governmentjobs. com)<https://www.governmentjobs.com/careers/ sdcounty/jobs/3148610/m-d-d-o-medical-consultant21416207?keywords=medical%20consultant&pagetype =jobOpportunitiesJobs

PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/ month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

MEDICAL CONSULTANT, SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/sdcounty?keywords=21416207

KAISER PERMANENTE SAN DIEGO, PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/specialty/ physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at (866) 503-1860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer.

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700.

FAMILY MEDICINE OR INTERNAL MEDICINE

PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director21226701UPH

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NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County. High Quality Family Practice for a privatenonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org.

PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other lowincome, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

PHYSICIAN POSITIONS WANTED

PART-TIME CARDIOLOGIST AVAILABLE AFTER 7/4/23: Dr. Durgadas Narla, MD, FACC is a noninvasive cardiologist looking to work 1-2 days/week or cover an office during vacation coverage in the metro San Diego area. He retired from private practice in Michigan in 2016 and has worked in a San Marcos cardiologist office for the last 5 years, through March 2023. Board certified in cardiology and internal medicine. Active CA license with DEA, ACLS, and BCLS certification. If interested, please call (586) 206-0988 or email dasnarla@gmail.com

PSYCHIATRIST AVAILABLE! Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla and San Diego. Visit hylermed.com or call (619) 707-1554.

PRACTICE FOR SALE

GASTROENTEROLOGY GI PRACTICE FOR SALE: Looking to expand or move? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years, even through pandemic. Located in a professional-medical building with professional contract staff. All records and billing managed by a professional service, who can assist with insurance integration. Office, staff and equipment are move-in ready. Seller will assist Buyer to ensure a smooth transition. Being on-call optional. Contact Ferdinand at (858) 752-1492 or ferdinand@zybex.com

OTOLARYNGOLOGY HEAD & NECK SURGERY

SOLO PRACTICE FOR SALE: Otolaryngology Head and neck surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at (858) 354-1895 or email: mahdavim3@gmail.com

OFFICE SPACE/REAL ESTATE AVAILABLE

ENCINITAS MEDICAL SPACE AVAILABLE: Newly updated office space located in a medical office building. Two large exam rooms are available M-F and suitable for all types of practice, including subspecialties needing equipment space. Building consists of primary and specialist physicians, great for networking and referrals. Includes access to the break room, bathroom and recep -

LA JOLLA/ UTC OFFICE TO SUBLEASE OR SHARE

Modern upscale office near Scripps Memorial, UCSD hospital, and the UTC mall. One large exam/ procedure room and one regular-sized exam room. Large physician office for consults as well. Ample waiting room area. Can accommodate any specialty or Internal Medicine. Multiple days per week and full use of the office is available. If interested please email drphilipw@gmail.com.

tion. Large parking lot with free parking for patients. Possibility to share receptionist or bring your own. Please contact coastdocgroup@gmail.com for more information.

NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista CA 92082. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, decor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is not included. For inquiries contact hosalkarofficeassist@ gmail.com or call/text (858) 740-1928.

PHYSICIAN OFFICE SPACE FOR LEASE: 1500 Sq ft. 3 exam rooms. Large private office. Large reception area and patient prep room. New upgraded flooring. Private entrance. Located in Rancho Bernardo in prime central location. Easy access to interstate 15. Palomar/Pomerado within 10 min. Security card access during off hours. $2500/month. Contact: (619) 585-0476. Ask for Peg.

HILLCREST OFFICE TO SUBLEASE OR SHARE: Gorgeous office located across from Scripps Mercy hospital. Office is approximately 2000 sq. ft. with procedure/effusion room. Office is fully staffed and looking to add a new provider. We currently have Rheumatology/Pulmonary/ Allergy specialists but can accommodate any specialty or Internal Medicine. Multiple days per week and full use of office is available. If interested please reach out to Melissa Coronado at Melissa@sdpulmonary.com or call (619) 819-7224.

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway. Share rent. 2100 sq ft office in professional building. Utilities included. Great opportunity in a very desirable area. (858) 342-3104.

CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2000sf, excellent parking ratios, Lease $4,000/mo. No need to spend a penny. Call Dr. Vin, (619) 405-6307 vsnnk@yahoo.com

OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500sq feet suite available to lease, includes private bathroom. Located at beautiful Bankers Hill. For more details, please call Claudia at (619) 501-4758.

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com.

OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking Doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information please contact Katia at (760) 427-3328 or email at Feminacareo@gmail.com

OFFICE SPACE / REAL ESTATE WANTED

MEDICAL OFFICE SPACE WANTED IN HILLCREST/ BANKERS HILL AREA. Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@sbcglobal.net or (858) 945-0903.

MEDICAL EQUIPMENT / FURNITURE FOR SALE

UROLOGY OFFICE CLOSING 6/2023—EQUIPMENT

AVAILABLE: Six fully furnished exam rooms including tables (2 bench, 3 power chair/table, 1 knee stirrup), rolling stools, lights, step stools, patient chairs. Waiting room chairs, tables, magazine rack. Specialty items — Shimadzu ultrasound, SciCan sterilizer, Dyonics camera with Sharp monitor, Medtronic Duet urodynamics with T-DOC catheters, Bard prostate biopsy gun with needles, Cooper Surgical urodynamics, Elmed ESU cautery, AO 4 lens microscope. RICOH MP-3054 printer with low print count. For more information contact: r.pua@cox.net.

NON-PHYSICIAN POSITIONS AVAILABLE

ASSISTANT, ASSOCIATE, OR FULL SPECIALIST (FY23-24) BASIC SCIENCE, MOLECULAR BIOLOGY, NEUROSCIENCES OR RELATED: Job #JPF03634 INST OF ENG IN MEDICINE / Other Departments / UC San Diego Apply now: https://apol-recruit.ucsd. edu/JPF03634/apply View this position online: https:// apol-recruit.ucsd.edu/JPF03634 Position title: Assistant, Associate, or Full Specialist Salary range: A reasonable salary range estimate for this position is $56,600$137,600. The posted UC academic salary scales (https://www.ucop.edu/academic-personnel-programs/ compensation/2022-23-academic-salary-scales.html) set the minimum pay determined by rank and/or step at appointment. See the following table for the salary scale for this position https://www.ucop.edu/academicpersonnel-programs/_files/2022-23/july- Application

Open date: June 14, 2023, Next review date: Thursday, Jun 29, 2023 at 11:59pm (Pacific Time) Apply by this date to ensure full consideration by the committee. Final date: Thursday, Aug 31, 2023 at 11:59pm (Pacific Time)

PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research Affairs https:// research.ucsd.edu/, in support of the campus multidisciplinary Organized Research Units (ORUs) https:// research.ucsd.edu/ORU/index.html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding. https:// apol-recruit.ucsd.edu/JPF03262/apply

OFFICE MANAGER: 1. Hiring, Training, Managing staff on procedures/policies. Monitors continuing compliance and office statistics. Oversee stocking/maintenance of supplies, retail. Equipment/facilities management. Daily bookkeeping, collections. 2. Ensure smooth/efficient patient flow with increasing production/collections. 3. Create a friendly environment where patients expectations are exceeded, where staff can work together as a team. 4. Ensure staff working at maximum productivity/ efficiency. Salary: $60-70K depending on experience/ qualifications. Benefits: health care reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@manageyourage.com

ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.