September 2024 by San Diego Physician

Diagnosing and Treating Alcohol Use Disorder in San Diego

Getting Patients the Help They Need and Preventing Liver Disease

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: Steve H. Koh, MD

President–Elect: Preeti S. Mehta, MD

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

Secretary: Maria T. Carriedo-Ceniceros, MD

Treasurer: Karrar H. Ali, DO, MPH

GEOGRAPHIC DIRECTORS

East County #1: Catherine A. Uchino, MD

East County #2: Rachel Van Hollebeke, 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: Toluwalase (Lase) A. Ajayi, MD

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

North County #1: Arlene J. Morales, MD (Board Representative to the Executive Committee)

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 D. 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

Retired Physician: Mitsuo Tomita, MD

Medical Student: Kenya Ochoa

CMA OFFICERS AND TRUSTEES

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 Alternate: Sergio R. Flores, MD

At–Large Alternate: Bing Pao, MD

CMA DELEGATES

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

District I: Vikant Gulati, MD

District I: Eric L. Rafla-Yuan, MD

District I: Ran Regev, MD

District I: Quinn Lippmann, MD

District I: Kosala Samarasinghe, MD

District I: Thomas J. Savides, MD

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

Opinions expressed by authors are their own and not necessarily those of SanDiegoPhysician or SDCMS. SanDiegoPhysicianreserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in SanDiegoPhysicianin no way constitutes approval or endorsement by SDCMS of products or services advertised. SanDiegoPhysicianand SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. SanDiegoPhysicianis published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

VOLUME 111, NUMBER 8

FEATURE

6 Diagnosing and Treating Alcohol Use Disorder in San Diego By James Dunford, MD and Tarek Hassanein, MD

DEPARTMENTS

Briefly Noted: Practice Management • Advocacy • Cannabis Regulation

4 Substance Abuse: New Interactive Maps for San Diego Physicians and Patients By Sayone Thihalolipavan, MD, MPH

United in Crisis: San Diego’s Healthcare Leaders Reflect on Four Years of Collaboration By Daphnie Tseng and William Tseng, MD, MPH

San Diego Physicians Lead Effort to Move American Medical Association Forward at Chicago Annual Meeting By Kyle P. Edmonds, MD, FAAHPM

Yes on Prop 35 By California Medical Association

Bird Flu Cases Are Going Undetected, New Study Suggests. It’s a Problem for All of Us. By Amy Maxmen

California Speeds Up Indoor Heat Protections Amid Sweltering Weather By Samantha Young

21 Classifieds

PRACTICE MANAGEMENT

AMA Publishes Provisional CPT Code for Avian Flu Vaccine

THE PROVISIONAL CPT CODE is effective for use on the condition the H5N8 Influenza virus vaccine candidates receive emergency use authorization from the U.S. Food and Drug Administration (FDA). The American Medical Association (AMA) is publishing the CPT code update now to ensure electronic systems across the U.S. healthcare system are prepared in advance for the potential FDA authorization.

A CPT code that clinically distinguishes the avian influenza vaccine allows for data-driven tracking, reporting and analysis that supports planning, preparedness, and allocation of vaccines in case a public health response is needed for avian flu prevention.

The new product code assigned to H5N8 influenza virus vaccines is:

• 90695: Influenza virus vaccine, H5N8, derived from cell cultures, adjuvanted for intramuscular use

The new CPT code for H5N8 influenza virus vaccines should be used with one of the following administration codes to report the work counseling patients or caregivers, administering the

vaccine and updating the medical record. For children (through 18 years of age) the administration codes are:

• 90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified healthcare professional; first or only component of each vaccine or toxoid administered

• 90461: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified healthcare professional; each additional vaccine or toxoid component administered For adults the administration codes are:

• 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

• 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid)

Prop 35 Campaign Unveils New Action Center; Physicians Encouraged to Take Action Now

PROP 35, THE NOVEMBER BALLOT

initiative that would secure dedicated funding to keep hospitals, clinics, and doctors’ offices open, has launched a new Action Center to activate supporters.

Physicians are trusted messengers across regional and partisan lines and are important advocates to ensure California votes “yes” on 35 to protect and expand access to healthcare. Visit the Action Center now to:

• Share Your Story: In your own words, tell us why you support Prop 35.

• Post on Social Media: Share with your friends and family why you are voting #Yeson35.

• Order Campaign Swag: Request campaign materials for you to show your support.

• Email a Friend: Tell your friends and family why you support YES on 35!

• Download Materials: Get the latest campaign materials.

Why We Need Prop 35

Critically, Prop 35 will prevent the state from redirecting revenues for non-healthcare purposes. Prop 35 will secure ongoing revenue — without raising taxes on individuals or increasing healthcare premiums — and dedicate these funds to protect and expand access to care for all Californians.

Our healthcare system is in crisis. Hospitals and maternity wards are closing — 46 California hospitals have closed their maternity wards since 2014. Emergency rooms are overcrowded with patients waiting an average of three hours, and patients often wait months to see a doctor. California has dramatically expanded healthcare coverage and services, but care for 15 million children, seniors, disabled, and low-income families with Medi-Cal coverage is significantly underfunded. Prop 35 will change that. Visit voteyes35.com for more information.

Understanding and Preventing Suicide Among Children and Teens

September is National Suicide Prevention Month, a time to remember people who died by suicide and raise awareness of the risk factors.

“Suicidal thoughts and attempts do not typically occur out of the blue,” says Dr. Jen Wojciechowski, a clinical child psychologist at Sharp Mesa Vista Hospital. “There are often early warning signs indicating someone is struggling prior to a suicide attempt.”

It has become increasingly important to know and understand these warning signs. According to the Centers for Disease Control and Prevention, the suicide rate increased 62% from 2007 to 2021 among people ages 10 to 24. A contributing factor to this rise is the mental health impact of the COVID-19 pandemic.

“The pandemic’s impact on youth is not yet fully understood, but it’s safe to say the pandemic took a toll on everyone, including children,” says Dr. Wojciechowski. “Social connections, which are paramount to healthy childhood development, were severely interrupted.”

Another factor in declining child and adolescent mental health is the rising use of online media.

“Being chronically online has led to more feelings of isolation, stress and inadequacy as children constantly compare themselves to others,” says Dr. Wojciechowski.

Early Warning Signs

Here are some early warning signs that a child may be struggling with their mental health:

• Mood swings Distressing thoughts Anxiety

• Impulsive behavior

• Decreased enjoyment when spending time with friends and family Declining academic performance, class attendance or motivation

• Persistent irritability

• Low energy levels

• Changes in eating and sleeping patterns Frequent physical complaints

Suicide Risk Factors

Certain signs that are more serious and may lead to depression or ideations of suicide include:

• Hopelessness

• Crying spells

• Persistent sadness

• Increased anxiety Disinterest in personal hygiene and appearance Engagement in high-risk behaviors

• Self-injury

• Verbal or physical aggression

Substance use

“Be vigilant if a young person lacks a sense of connection or belonging with others, expresses having no purpose or reason to live, or persistently talks about death or feeling like a burden on others,” says Dr. Wojciechowski.

Seeking Specialized Support

If you have a patient who could benefit from additional support, Sharp Mesa Vista Hospital provides compassionate treatment to children and teens experiencing serious behavioral and emotional challenges.

“The child and adolescent outpatient programs at Sharp Mesa Vista create a sense of connection and foster the development of healthy coping skills young people need to effectively navigate their life at home, at school and within the community,“ says Dr. Wojciechowski.

CANNABIS REGULATION

CMA Backs DEA’s Proposal to Further Research Medical Benefits and Limitations of Cannabis

THE CALIFORNIA MEDICAL ASSOCIATION (CMA)

and the Medical Cannabis Research Advocacy Alliance (MCRAA) submitted comments to the U.S. Department of Justice (DOJ) and U.S. Drug Enforcement Agency (DEA) supporting the DEA’s proposal to re-classify cannabis from a Schedule I to a Schedule III under the Controlled Substances Act (CSA) Schedule.

“Without such changes to the scheduling of this medication and treatment, we fear that the ongoing research will be further limited,” MCRAA and CMA stated. “The only way to truly identify benefits and opportunities in treatment utilizing medical cannabis is through clinical trials and research that allow clinicians and patients to fully access this medication, and this simply cannot be done today with the existing scheduling assigned by the DEA.”

The letter noted the U.S. Department of Health and Human Services (HHS), which is considered the agency best equipped to evaluate the medical use of cannabis, concluded “the risks to the public health posed by marijuana are low compared to other drugs of abuse,” and that “[n]o safety concerns were identified in our review that would indicate that the medical use of marijuana poses unacceptably high safety risks for the indications where there is some credible scientific evidence supporting its therapeutic use.”

Additionally, surveys have shown there is widespread support among health professionals for the use of medical cannabis. A 2022 survey of family practice doctors, internists, nurse practitioners, and oncologists found that over two-thirds (68.9%) believe that cannabis has medicinal uses, and a 2022 survey of members of the American Organization for Nursing Leadership found that “Nurse leaders overwhelmingly supported patients’ use of medical cannabis.”

SUBSTANCE ABUSE

New! Interactive Maps for San Diego Physicians and Patients

Locator Maps to Access Substance Use Disorder Treatment, Medication Assisted Treatment (MAT), Naloxone, and Safe Medication Disposal Sites

By Sayone Thihalolipavan, MD, MPH

AS PHYSICIANS, WE OFTEN FIND OURSELVES at the forefront of addressing complex health issues, including substance use disorders (SUDs). Many of us have encountered patients struggling with addiction or seeking guidance on proper medication disposal. If you’ve ever found yourself searching for comprehensive resources to support these patients, there’s good news. New interactive websites are now available you, your team, and your patients!

A

One-Stop

Resource for Critical Needs

These platforms serve as centralized hubs, offering locations of three essential services:

1. Substance Use and MAT Treatment Locations

2. Safe Medication Disposal Locations

3. Naloxone Distribution Locations

The Substance Use and Overdose Prevention Taskforce (SUOPT) is a countywide collaborative of health and public safety partners. If you are interested in joining SUOPT’s Health Care Task Force or receiving information about SUOPT general meetings, please visit SUOPT.org and fill out the contact information at the bottom of the page. In addition, local statistics can be found on their Annual Report Card page.

Dr. Thihalolipavan is a public health medical officer in the Medical Care Services Department at the County’s Health and Human Services Agency.

San Diego County Substance Use and Overdose Prevention Taskforce

Supporting Our Community, Saving Lives Together

Welcome to the San Diego County Substance Use and Overdose Prevention Taskforce! Our mission is to provide essential resources and support to individuals and families affected by substance use and overdose in our community. Visit SUOPT.org to access:

Resource Hub: Find valuable resources, toolkits, and handouts to help you or a loved one navigate substance use challenges.

Education and Awareness: Discover informative training videos and materials to increase your understanding of substance use disorders and prevention strategies

Education and Awareness: Discover informative training videos and materials to increase your understanding of substance use disorders and prevention strategies.

Support Services: Connect with local support groups, counseling services, and treatment options to get the help you need.

Resource Highlight: Scan the QR code to learn where to dispose of unwanted medications in San Diego County.

Resource Highlight: Scan the QR code to learn where to access treatment resources and naloxone throughout San Diego County.

Resource Highlight: Scan the QR code to learn where to access treatment resources and n l throughout San Diego County.

DIAGNOSING AND TREATING ALCOHOL USE DISORDER IN SAN DIEGO

Coordination for this article was provided by the Liver Coalition of San Diego, an organization dedicated to promoting liver health and addressing the needs of those affected by liver disease.

ALCOHOL IS THE most frequently used drug throughout the world. It has depressant effects on the central nervous system and affects cognition, perception, and emotions similar to other recreational drugs such as marijuana, LSD, and cocaine, as well as medicinal drugs such as Xanax, Ambien, and Valium. While side effects range from blurred vision and dizziness to euphoria, it is considered a carcinogen and can lead to alcoholinduced organ damage and death in high doses. The World Health Organization (WHO) identified alcohol as a causal factor in more than 200 diseases, injuries, and other health conditions. The previously reported health benefits of moderate alcohol use have recently been challenged in well-designed clinical and epidemiologic trials. Even low levels of alcohol intake have well-documented effects on overall mortality in users. Heavy alcohol drinking (more than eight drinks per occasion) increases the risks for numerous complications and increases mortality. Over the next two decades, alcohol use disorder (AUD) is projected to cost $355 billion in direct healthcorrelated costs. Getting Patients the Help They Need and Preventing Liver Disease

By James Dunford, MD and Tarek Hassanein, MD

Screening for Unhealthy Alcohol Use

When assessing for hazardous drinking or active AUD, remember that the definition of a standard drink varies by beverage: 12 ounces of regular beer (5% alcohol), 5 ounces of wine (12% alcohol), or one shot (1.5 ounces) of spirits (80% alcohol). For adults, the US Preventive Services Task Force recommends the following brief initial screeners:

The Alcohol Use Disorders Identification TestConcise (AUDIT-C) consists of three questions, with each response rated 0–4: “How often do you have a drink containing alcohol? How many standard drinks containing alcohol do you have on a typical day? How often do you have six or more drinks on one occasion?” A score of 3 or more for women (4 or more for men) is considered positive, warranting full screening with the 10-question AUDIT.

The National Institute on Alcohol Use and Alcoholism (NIAAA) Single Alcohol Screening Question (SASQ) asks: “How many times in the past year have you had [4 for women, 5 for men] or more drinks in a day?” A score of 0–1 indicates low risk; a score of 2 or higher is positive and indicates the need for additional screening.

Definition of Alcohol Use Disorder (AUD)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) considers 11 criteria to determine the presence and severity of AUD (as

shown in Table 1).

Each element should be assessed within the context of a patient’s alcohol use over the past year. AUD severity is defined by the number of criteria met: 2–3=mild; 4–5=moderate; 6+=severe. Severe AUD is considered an “addiction.” FDA-approved medications are indicated for moderate and severe AUD. Like other illnesses, AUD worsens over time without treatment.

Demographics and Cascade of Care

As of 2023, 14.8 million individuals (i.e., 1 in 10 over the age of 12) met criteria for AUD. Males are disproportionately affected (men 62.7%, women 35.6%, adolescents 2.7%). For a variety of reasons, including insurance barriers, limited provider knowledge and time, patient reluctance, ineffective care coordination, and social stigma, a downward “cascade of care” dramatically limits the treatment of AUD. Unfortunately, despite evidence-based, FDA-approved medications and a rising rate of alcohol abuse, only 27% percent of individuals with moderate or severe AUD receive medical treatment today, as shown in Figure 1.

Alcohol-Associated Liver Disease

Alcohol-associated liver disease is a common complication of AUD. Hepatologists currently call any liver injury from alcohol “alcohol-associated liver disease (ALD),” and it is subdivided into alcohol-induced steatosis, alcoholic steatohepatitis (ASH), alcoholic hepatitis (AH) of varying degrees of severity, alcoholic cirrhosis, and alcoholic cirrhosis with hepatocellular cancer (HCC). Alcohol intake causes fatty liver (steatosis) in 90% of individuals. Long-term drinking induces progression in steatosis to steatohepatitis and liver fibrosis. Progressive liver fibrosis leads to portal hypertension, cirrhosis, and HCC.

Table 1. DSM-5 Criteria for AUD

Loss of Control

• larger quantity over longer period of time unsuccessful attempts to cut back

• increased time spent

Consequences

• failure to fulfill major role obligations social/ interpersonal problems

• activities given up use in hazardous situations

Cravings

• physical and psychological consequences craving

• tolerance

• withdrawal

Figure 1. The “Cascade of Care” for AUD

Figure 1: Management of Alcoholic Hepatitis (AH)

GI, gastrointestinal; IV, intravenous; MDF, Maddrey Discriminant Function; MELD, Model for End-Stage Liver Disease; NAC, N-acetylcysteine.

Alcoholic Hepatitis (AH)

Severe AH is seen in individuals who drink excessively and has poor prognosis and a high mortality rate. AH is a condition characterized by severe hepatocyte injury leading to cellular metabolic failure and impaired overall regeneration and differentiations. In the presence of altered intestinal permeability and dysbiosis, the patient’s condition deteriorates rapidly, resulting in sepsis, multi-organ failure, and death. The reported mortality rate of patients presenting with severe AH in 28 days is 26%; by day 90, the mortality rate reaches 40–50%.

Management of AH is challenging and requires attentive and close observation of the patients as they rapidly progress in their liver cell failure to progressive cholestasis and ultimately sepsis, hepatorenal syndrome, and other organ

failures (Figure 1). The Maddrey Discriminant Function (MDF), the Model for End-Stage Liver Disease (MELD) score, and the Lille Model for Alcoholic Hepatitis are commonly used to categorize these patients as they progress through the disease.

Early in disease, patients have to abstain from alcohol, improve their nutrition status with supplemental feeding, and avoid any infections. Antibiotics and hemodynamic support with intravenous (IV) colloids (controlled doses), and occasionally vasopressors, are encouraged. Corticosteroids are indicated for patients with MDF > 32 and/or MELD >20, who have no contraindication for steroids use, such as active infections, gastrointestinal bleeding, acute renal injury (creatinine > 2.5 md/dL), concurrent viral infections, pancreatitis, or other organ failure. Once corticosteroids are started, the Lille score can predict responders versus non-responders. Responders will decrease their total bilirubin by 20% by day four to seven. A Lille score of > 0.45 at day seven indicates non-response and suggests termination of steroids for non-efficacy. If the Lille score is <0.45, then corticosteroids can be continued for 28 days only. More recently, Nacetylcysteine (NAC) had been co-administered with corticosteroids to improve the 28-day survival benefit. Failure of corticosteroids/ NAC therapy, or presence of contraindication for corticosteroids, would result

in a higher mortality rate. Referral to a liver transplant center should be considered for all patients. Transplant centers and their teams should make the ultimate decision for transplant eligibility and not other care providers. Patients who are not transplant candidates continue to progress in their disease, manifesting worsening of cholestasis and hyperbilirubinemia. However, with proper support, the majority of these patients (>50%) recover, albeit over a long time (weeks). Extracorporeal albumin detoxification (ECAD) is an approach that ameliorates cholestasis and provides recovery. ECAD can be provided by different techniques including single-pass albumin dialysis, molecular absorbent recirculating system, or plasmapheresis using albumin.

The estimated number of hospitalized patients with severe AH in the US exceeds 137,000/year. Their average length of stay is six to nine days. The cost of hospitalizations ranges from $53,000 for patients who get discharged from the hospital to as much as $147,000 for patients who end up dying at the hospital. Patients who fail hospital management and are not transplant candidates per liver transplant specialists should be offered palliative care after coordination with their family, primary caregivers, primary care physicians, hospital staff, and the palliative care teams. A good number of patients who

achieve abstinence and continue supportive and coordinated care recover from AH and survive their disease.

Access to Alcohol Use Disorder (AUD) Treatment in San Diego

There are multiple points of access to care for AUD in San Diego, including the 988 San Diego Access and Crisis Line and the County of San Diego Behavioral Health Provider Directory (sdcountybhs.com/ProviderDirectory). In addition, the County contracts with community-based organizations for substance use disorder (SUD) services including withdrawal management (detox) and residential treatment, outpatient clinics (some just for women with children), adolescent group homes, and teen programs. McAlister Institute (mcalisterinc.org) offers 20 SUD programs across the region.

Drug Medi-Cal Organized Delivery System

On July 1, 2018, San Diego County implemented the California Drug Medi-Cal Organized Delivery System (DMC-ODS) after a University of California-Los Angeles (UCLA)-led pilot study determined the approach improved access to treatment and enhanced care coordination and integration with physical health services. DMC-ODS incorporates the American Society of Addiction Medicine’s (ASAM) continuum of care model for SUD treatment. Participating counties provide clients with multiple levels of residential treatment as well as withdrawal management, recovery services, physician consultation, medication-assisted treatment (MAT), and partial hospitalization. While DMC-ODS incorporates the essential elements of SUD treatment, gaps remain between physical and mental healthcare. This is problematic since cooccurring mental health conditions are common in patients with SUD. For example, 41% of clients with AUD have an independent mood disorder and 33% have an independent anxiety disorder.

Level of Services

To determine the initial level and urgency of needed SUD services, intake workers perform ASAM screening that assesses six dimensions of the prospective client, including (1) acute intoxication or withdrawal potential; (2) biomedical conditions and complications; (3) emotional, behavioral, and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovering/living environment.

A resulting severity score suggests the appropriate level of care:

Prevention/Early Prevention

Level 1: Outpatient

Level 2: Intensive Outpatient/Partial Hospitalization

Level 3: Residential/Inpatient

Level 4: Intensive Inpatient

For example, a client requiring Level 2.1 (Intensive Outpatient Services) would be offered 9–19 hours of structured, professionally directed programming per week conducted

by counselors, psychologists, social workers, and staff crosstrained to interpret mental disorders. A client in withdrawal, on the other hand, would receive prompt referral to an emergency department or clinic capable of providing such care.

Behavioral Therapy

Evidence-based psychotherapeutics provided in SUD treatment programs include cognitive behavioral therapy, motivational enhancement, and contingency management. These techniques are introduced during individual and group counseling, educational groups, occupational and recreational therapy, and family therapy. Clients are also linked to mutual support groups including Alcoholics Anonymous and other 12-step-like programs, which have demonstrated benefit in achieving sustained abstinence and percentage days abstinent.

Importantly, treatment success is not defined by complete abstinence from alcohol. A reduction in alcohol consumption leads to improved health, quality of life, and lower mortality rates. Epidemiologic studies consistently associate high average alcohol consumption and heavy per-occasion use with cancers (mouth, esophagus, colon, liver, breast), cognitive impairment, liver cirrhosis, chronic pancreatitis, stroke, depression, suicide, injuries, and violence.

Medication-Assisted Treatment (MAT)

MAT for AUD is evidence-based treatment; when combined with counseling and other therapeutic techniques, it relieves psychological cravings and is an essential element of SUD care today. The Substance Abuse and Mental Health Services Administration provides free training and mentoring to medical practitioners to identify and treat AUD (www. samhsa.gov/medications-alcohol-use-disorders-pcss-maud).

Figure 2. Co-occurring Mood and Anxiety Disorders in Patients with AUD

Primary Care and Emergency Department

Personnel: We Can Do More

Despite the demonstrated efficacy of treatments for alcohol use disorder (AUD), they are underutilized, because of stigma surrounding alcohol misuse and treatment, insufficient screening and referral practices, and lack of awareness that these medications are viable treatment choices.

The Liver Coalition of San Diego and A New Path are working with community partners to increase awareness of these treatment options. Initiating treatment of AUD with extended-release naltrexone and case management is feasible in an emergency department (ED) setting. A 12week, prospective, open-label, single-arm study at an urban academic ED observed significant reductions in drinking with improved quality of life in the short term. In the study, of 179 patients approached, 32 were enrolled (18%). Of those enrolled, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the study.

The median daily alcohol consumption change was −7.5 drinks per day (Hodges-Lehmann 95% CI, −8.6, −5.9), and the mean quality of life change was 1.2 points (95% CI, 0.5, 1.9; P<.01). The study found that initiation of treatment of AUD with case management is feasible in an ED setting.

Left: A symbol for hope and a celebration of recovery, the community unites at McAlister Institute’s annual Walk for Sobriety. Pictured: Scott Suckow, executive director of the Liver Coalition; Gretchen Bergman, executive director and co-founder of A New Path; and Caroline Ridout Stewart, MA, MSW, LCSW, who serves as board president of A New Path. Right: Destigmatizing Medication-Assisted Treatment (MAT) is an ongoing series of seminars to educate the community on harm reduction. Pictured are panelists with Gretchen Bergman, executive director and co-founder of A New Path, moderating the discussion.

Until recently, SUD counselors had to rely on primary care providers and emergency physicians to prescribe MAT medications for their clients. Effective in 2023, San Diego’s MCLODS providers have begun implementing on-site (including telehealth) MAT services for AUD using physician extenders.

Current Medication Options

Disulfiram (Antabuse) is an alcohol-sensitizing agent approved by the FDA in 1949 for the treatment of AUD. It blocks the conversion of acetaldehyde to acetic acid, resulting in nausea, flushing, headache, and, rarely, vasomotor collapse. Though not recommended as a part of the modern approach to AUD, some clients find it helpful if taken in advance of attending events where alcohol is likely to be served.

Naltrexone is an opioid antagonist that was FDA-approved in oral form in 1994, and subsequently approved in extendedrelease injectable (intramuscular [IM] monthly) suspension (Vivitrol) in 2010, to treat moderate and severe AUD. The American Psychiatric Association (APA) Guidelines for Pharmacological Treatment of AUD rate the strength of naltrexone’s effectiveness as 1-B. Both oral and injectable forms of naltrexone are covered by Medi-Cal. While safe to begin during medically supervised withdrawal or while actively drinking, oral naltrexone (starting with a half-dose of 25mg per day) is typically begun following three days of abstinence to avoid nausea. The FDA daily recommended dose is 50mg, but higher doses have been shown to offer added benefit. Extended-release (IM) naltrexone improves adherence, treatment retention, abstinence, and cravings in AUD. Since naltrexone is also effective in treating opioid use disorder, the sustained release formulation is well suited for co-occurring diagnoses and criminal justice settings. Naltrexone is contraindicated in acute hepatitis, advanced liver failure, concurrent opioid use, and if there is an anticipated need for opioids (eg, elective surgery).

Acamprosate (Campral) was approved by the FDA in 2014 for treatment of AUD. The APA rates its evidence of effectiveness as 1-B. It is an amino acid derivative that increases gamma-aminobutyric acid (GABA) transmission as well as altering excitatory glutaminergic neurotransmitter systems involved in alcohol dependence. Similar to naltrexone, acamprosate improved total abstinence (RR = 1.33; 95% CI, 1.15–1.54) and reduced heavy drinking (RR = 0.78; 95% CI, 0.70–0.86). Treatment should begin as soon as possible after a period of alcohol withdrawal, titrating upward to two tablets (666 mg per dose) three times per day. The primary side effects are diarrhea, bloating, and pruritis. Evaluation of renal function prior to initiation is warranted in the elderly and those with risk factors for renal disease.

A 2022 meta-analysis of 156 randomized control trials involving 27,334 patients and five decades of research concluded that oral naltrexone and acamprosate had similar efficacy in reducing heavy drinking and promoting abstinence versus placebo. Oral naltrexone improved total abstinence (relative risk [RR]= 1.15; 95% CI, 1.01–1.32) and reduced

heavy drinking (RR = 0.81; 95% CI, 0.73–0.90). Targeted oral naltrexone had similar efficacy with fewer adverse effects than when daily-dosed, which makes this approach worth considering in patients with lower adherence, treatment retention, or significant side effects or in those not meeting full AUD criteria.

Potential Future Medication Options

While a variety of other medications including baclofen, gabapentin, pregabalin, topiramate, nalmefene, and fluvoxamine are used to treat AUD, none of them are FDA-approved for this indication or covered by Medi-Cal. Recently, a phase IIa trial at Scripps Research Institute found that apremilast (Otezla), a phosphodiesterase-4 (PDE4) inhibitor already approved for treatment of psoriasis, suppressed excessive alcohol drinking across the spectrum of AUD severity. Its mechanism of action likely modifies neural activity in the nucleus accumbens, an area of the brain that plays an essential role in both the rewarding effects of alcohol (and other substances) and the ability of stimuli associated with these substances to trigger craving, substance seeking, and use.

Conclusion

In general, the goals of treating AUD are to reduce and manage symptoms and improve health and functioning. Most individuals with AUD do not require residential treatment. Less intense, evidence-based care combining medications and behavioral treatments are available through primary care physicians, community-based treatment programs, and community mutual-aid groups. It is essential that physicians redouble their efforts to screen for AUD, prescribe MAT, and partner with local SUD programs to maximize patient access to these beneficial resources.

If you would like a copy of this article with citations and source listing, please email editor@sdcms.org.

James Dunford, MD is emeritus professor of Emergency Medicine at UC San Diego School of Medicine, where he practiced from 1980 to 2017. From 1997 to 2017, he also served as the City of San Diego Emergency Medical Services medical director. In 2018, Dr. Dunford became the medical director of McAlister Institute (www.mcalisterinc.org), the region’s largest substance treatment program for Medi-Cal patients. Tarek Hassanein, MD, is board certified in internal medicine, gastroenterology, and transplant hepatology. Dr. Hassanein specializes in treating alcohol-associated liver disease, as well as other liver diseases, and in caring for patients before and after liver transplantation. Dr. Hassanein is the medical director of Southern California GI & Liver Centers (www.livercenters.com).

Photographs by Brett Hoffman

United in Crisis: San Diego’s Healthcare Leaders Reflect on Four Years of Collaboration

By Daphnie Tseng and William Tseng, MD, MPH

IN 2020, COVID-19 TRANSMISSION SURGED DAILY to unprecedented pandemic heights, and the need for healthcare systems collaboration was urgently clear.

Faced with limited data in an evolving crisis, chief medical officers from San Diego County’s largest healthcare systems — Kaiser Permanente, Navy Medical Center, Palomar Health, Rady Children’s, Scripps Health, Sharp HealthCare, Tri-City Medical Center, UCSD Health, and VA Healthcare — came together with a solemn purpose: to better protect our community.

The CMOs connected to exchange critical insights and navigate the unknown, while developing strategies to shield the people of San Diego from the virus’s devastating impact. With the support of Dr. Nick Yphantides and the County of San Diego Health and Human Services, CMOs found strength in unity. Since 2020, San Diego area CMOs have met regularly via Zoom, Teams, and text.

After four years of virtual meetings, the group recently had a chance to connect in person. On August 19, the San Diego County Medical Society hosted a dinner gathering, attended by CEO Paul Hegyi, CMA CEO Dustin Corcoran, SDCMS President Steve Koh, and 10 healthcare systems leaders in the region.

The evening was filled with reflections on challenges the group had to overcome in the past four years; discussions of a shared commitment to the health of our greater San Diego community; and celebrations of success embedded in the spirit of trust, interdependence, honesty, and collaboration!

Looking ahead, as the devastating toll of the pandemic recedes, public health priorities continue to evolve as new issues emerge. Thus, policies to enhance patient care and improve cost efficiency must adapt to our changing population and demographics.

Corcoran, during the evening’s keynote presentation, highlighted the Proposition 35 “Protect Our Health Care” initiative as a solution to access quality healthcare.

With California’s current overcrowded emergency rooms and long wait times, Prop 35 aims to expand access to care

for vulnerable populations without increasing taxes. This initiative is crucial for Medi-Cal patients, especially since half of California’s children are covered under the program. By making these investments permanent, Prop 35 ensures consistent support for healthcare providers, alleviating strain on the system. With broad bipartisan support, Prop 35 promises a future where access to specialized care is quicker and the healthcare system is stronger and more resilient.

Furthermore, physician and staffing shortages continue to strain hospitals and organizations. However, the growing adoption of technologies like artificial intelligence offers a promising solution. By optimizing care, AI can potentially mitigate these shortages, easing the burden on physicians by enhancing efficiency in documentation and diagnosis. While many officers acknowledge the potential of this technology, they also remain cautious about its future role.

As the cost of quality care rises and becomes more specialized and comprehensive to meet the needs of our aging population, expanding or adapting programs and facilities to better serve this demographic is essential. Initiatives such as in-home support, hospital-at-home models, and telemedicine, which have evolved during the pandemic, are key strategies. With a commitment to improved policies, innovative technology, and a strong collaborative network, healthcare leaders can ensure that effective healthcare systems will continue to benefit everyone in our community.

What a memorable first San Diego Regional CMO evening!

Committed to community service, San Diego healthcare leaders deepened their bond over the mission of “promoting the science and art of medicine, the quality care and wellbeing of patients, and the public health of the community.”

With dedicated regional CMOs coming together to better serve our community, the future looks bright for San Diego!

Dr. Tseng is assistant medical director for Kaiser Permanente Southern California Medical Group. Daphnie Tseng is his daughter, who was voluntold to help research/ write/edit this article while on summer break.

San Diego Physicians Lead Effort to Move American Medical Association Forward at Chicago Annual Meeting

By Kyle P. Edmonds, MD, FAAHPM

JUNE FOUND ME ONCE AGAIN IN DOWNTOWN

Chicago at the AMA Annual Meeting, which represents one of two yearly opportunities to nudge the AMA in new directions. The meeting opened with the final address of outgoing president, Dr. Jesse Ehrenfeld, and closed with the inauguration of Dr. Bruce Scott, former speaker of the House of Delegates, as the new president. Both highlighted the urgent AMA focus on reforming Medicare, fixing prior authorization, reducing physician burnout, and uniting physicians.

Dr. Ehrenfeld set the tone for our meeting, casting an eye toward the future. “I began my presidency talking about the important ways the AMA has evolved since I was a medical student,” he said, “becoming a more inclusive organization and courageous ally to many, including myself, who faced prejudice or discrimination simply because of who they are, where they were born, or what they believe in. I am so proud of the AMA’s growth, and to have had a hand in helping us change for the better. We still have consequential work ahead of us: barriers to break down, inequities to erase, and shared priorities to advance.”

To advance the priorities of California physicians and our patients, the delegation to the AMA amplifies its voice as a key member of the PacWest Caucus, which is chaired by our own Dr. Al Ray and comprises the delegations from Alaska, Arizona, California, Colorado, Guam, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. At this meeting, we worked collaboratively with students, residents, and physicians from across this large swath of the country to impact policy on multiple topics including the preservation of the primary care relationship, equity in medical education, scope of practice, environmental resiliency in health systems and physician practices, and insurer accountability for harm caused by prior authorization. We specifically championed resolutions forwarded from the CMA House of Delegates on topics like access to reproductive health services, restorative justice for substance use disorders, biosimilar regulation, health sector contributions to the climate crisis, and reducing job-related climate risk factors. Many of these policies were adopted — including the suite of new policy on climate change that will energize the AMA’s work in that area.

In between discussions on policy, we celebrated the victo-

ries of some of our own. Surgical oncologist Dr. Steven Chen was reelected to the Council on Medical Services, and pediatrician and palliative medicine specialist, Dr. Toluwalase Ajayi, was elected as secretary of the Board of Trustees.

Nearby leaders also found success like Los Angeles ophthalmologist Dr. David Aizuss, who was reelected to the AMA Board of Trustees and then elected as chair-elect of the board, while Oxnard plastic surgeon Dr. Lynn Jeffers was elected to the Board of Trustees for the first time.

The spirit of the meeting was best captured in the inaugural address of the new president. “As a physician in an independent private practice, I live these issues every day,” said Dr. Scott, an otolaryngologist in Louisville, Kentucky. “I see my colleagues struggling,” he added. “I feel the urgency of the moment and I will bring that urgency to my presidency. You better believe I’m ready to fight. Fight for you. Fight for us. Fight for our profession. Fight for our patients.” And then Dr. Scott hosted a bourbon tasting featuring some of Kentucky’s finest.

Take Action to #FixMedicareNow

Dr. Edmonds is an inpatient palliative physician in 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. He offers his usual disclosure that he’s not impartial when it comes to AMA Trustee Dr. Lasé Ajayi, since the two have been married for many years.

Addressing our most urgent health care priorities. Here’s how you can help.

The California Medical Association (CMA) is a proud supporter of Proposition 35 , which will secure dedicated funding to keep hospitals, clinics and doctors’ offices open.

Why We Need Prop 35:

Our health care system is in crisis. Hospitals are closing. Emergency rooms are overcrowded. More than 40 hospitals have stopped offering labor and delivery services. Patients wait months to see a primary care doctor or specialist.

California has dramatically expanded health care coverage and services, but care for almost 15 million children, seniors, disabled and low-income families with Medi-Cal coverage is significantly underfunded. What’s more, continued challenges and divestment have made it increasingly hard to recruit and retain frontline health care workers.

CMA has joined a coalition of health care workers, community health centers, Planned Parenthood, health plans and emergency responders to pass Prop 35. And, Prop 35 is supported by both the California Democratic Party and the California Republican Party.

Prop 35 will secure ongoing revenue—without raising taxes—and dedicate these funds to protect and expand access to Medi-Cal. And most importantly, it will prevent the state from redirecting these revenues for non-health care purposes.

Prop 35 will:

+ Provide long-overdue rate increases for Medi-Cal providers and stabilize rates, to protect and expand access to care

+ Secure ongoing funding—without raising taxes on individuals—to ensure that our health care system has the resources it needs

+ Ensure health care funds aren’t redirected for non-health care purposes

+ Fund more graduate medical education residency programs to address the physician shortage

+ Fund loan repayments for physicians and allied health professionals

+ Expand access to preventative health care to alleviate the burden on ERs

+ Reduce wait times in emergency rooms and urgent care facilities

+ Help hire more first responders and paramedics to reduce emergency response times

Bottom line: Prop 35 will improve health outcomes for millions of Californians.

Get Involved:

The Prop 35 campaign has launched a new Action Center to activate supporters at voteyes35.com/take-actio n

Physicians are trusted messengers across regional and partisan lines and are important advocates to ensure California votes Yes on 35 to protect and expand access to health care. Visit the Action Center now to:

+ Share Your Story: In your own words, tell us why you support Prop 35.

+ Follow Yes on Prop 35 on Facebook, Instagram, LinkedIn and X and share our messages with your followers.

+ Post on Social Media: Share with your friends and family why you are voting #Yeson35 .

+ Order Campaign Swag: Request campaign materials for you to show your support. Sign up to receive campaign materials that you can share with friends, colleagues and patients.

+ Email a Friend: Tell your friends and family why you support YES on 35 !

+ Download Materials: Get the latest campaign materials.

+ Join the Coalition.

+ Make a Donation: Make an individual donation at voteyes35.com/donate . If you would like to make a group or medical staff donation, please email nskadsen@cmadocs.org .

Visit cmadocs.org/prop35 for more information.

Bird Flu Cases Are Going Undetected, New Study Suggests. It’s a Problem for All of Us.

By Amy Maxmen

A NEW STUDY LENDS WEIGHT TO FEARS THAT

more livestock workers have gotten the bird flu than has been reported.

“I am very confident there are more people being infected than we know about,” said Gregory Gray, the infectious disease researcher at the University of Texas Medical Branch who led the study, posted online Wednesday and under review to be published in a leading infectious disease journal. “Largely, that’s because our surveillance has been so poor.”

As bird flu cases go underreported, health officials risk being slow to notice if the virus were to become more contagious. A large surge of infections outside of farmworker communities would trigger the government’s flu surveillance system, but by then it might be too late to contain.

“We need to figure out what we can do to stop this thing,” Gray said. “It is not just going away.”

The Centers for Disease Control and Prevention bases decisions on its surveillance. For example, the agency has bird flu vaccines on hand but has decided against offering them to farmworkers, citing a low number of cases.

But testing for bird flu among farmworkers remains rare, which is why Gray’s research stands out as the first to look for signs of prior, undiagnosed infections in people who had been exposed to sick dairy cattle — and who had become ill and recovered.

Gray’s team detected signs of prior bird flu infections in workers from two dairy farms that had outbreaks in Texas earlier this year. They analyzed blood samples from 14 farmworkers who had not been tested for the virus and found antibodies against it in two. This is a nearly 15% hit rate from only two dairy farms out of more than 170 with bird flu outbreaks in 13 states this year.

One of the workers with antibodies had been taking medicine for a lingering cough when he agreed to allow researchers to analyze his blood in April. The other had recently recovered from a respiratory illness. She didn’t know what had caused it but told researchers that untested farmworkers around her had been sick too.

Richard Webby, director of the World Health Organization Collaborating Center for Influenza at St. Jude Children’s Research Hospital in Memphis, Tennessee, said the results confirmed his suspicions that the 13 human bird flu cases reported this year by the CDC were an undercount.

“Maybe what we see isn’t exactly the tip of the iceberg, but it’s certainly not the whole story,” Webby said.

Little Testing of Farmworkers

Although small, the study gives fresh urgency to reports of undiagnosed ailments among farmworkers and veterinarians. The CDC has warned that if people are infected by the seasonal flu and the bird flu simultaneously, the two types of viruses could swap genes in a way that allows the bird flu to spread between people as easily as seasonal varieties.

No evidence suggests that’s happening now. And asymptomatic cases of the bird flu appear to be rare, according to

a Michigan antibody study described by the CDC on July 19. Researchers analyzed blood samples from 35 workers from dairy farms that had outbreaks in Michigan, and none showed signs of missed infections. Unlike the study in Texas, these workers hadn’t fallen sick.

“It’s a small study, but a first step,” said Natasha Bagdasarian, Michigan’s chief medical executive. She said that the state was boosting outreach to test farmworkers but its efforts were complicated by systemic issues like precarious employment that renders them vulnerable to getting fired for calling out sick.

Without more assistance for farmworkers, and cooperation between the government and the livestock industry, Gray said, the U.S. risks remaining in the dark about this virus.

“There’s a lot of genomic studies and laboratory work, but farms are where the real action is,” Gray said, “and we’re not watching.”

Communication Breakdown

A dairy worker in Colorado told KFF Health News that he sought medical care about a month ago for eye irritation — a common symptom of the bird flu. The doctor conducted a usual checkup, complete with a urine analysis. But the farmworker hadn’t heard of the bird flu, and the clinician didn’t mention it or test for the virus. “They told me I had nothing,” he said in Spanish, speaking on the condition of anonymity because he feared retaliation from employers.

This dairy worker and two in Texas said their employers have not provided goggles, N95 masks, or aprons to protect them from milk and other fluids that could be contaminated with the virus. Buying their own gear is a tall order because money is tight.

As is going to the doctor. One worker in Texas said he didn’t seek care for piercing headaches and a sore throat because he doesn’t have health insurance and can’t afford the cost. He guessed the symptoms were from laboring long hours in sweltering barns with limited water. “They don’t give you water or anything,” he said. “You bring your own bottles.” But there’s no way to know the cause of symptoms — whether bird flu or something else — without testing.

About a fifth of workers on livestock farms are uninsured, according to a KFF analysis, and a similar share have household incomes of less than $40,000 a year.

The three farmworkers hadn’t heard of the bird flu from their employers or state health officials, never mind offers of tests. The CDC boasted in a recent update that, through its partnership with Meta, the company that owns Facebook and Instagram, bird flu posts have flickered across computer and smartphone screens more than 10 million times.

Such outreach is lost on farmworkers who aren’t scrolling, don’t speak English or Spanish, or are without smartphones and internet access, said Bethany Boggess Alcauter, director of research and public health programs at the National Center for Farmworker Health. She and others said that offers of protective gear from health officials weren’t reaching farms.

“We’ve heard that employers have been reticent to take them up on the offer,” said Christine Sauvé, policy and engagement manager at the Michigan Immigrant Rights Center. “If this starts to transmit more easily person to person, we’re in trouble,” she said, “because farmworker housing units are so crowded and have poor ventilation.”

Clinics might alert health officials if sick farmworkers seek medical care. But many farmworkers don’t because they lack health insurance and could be fired for missing work.

“The biggest fear we hear about is retaliation from employers, or that someone might be blacklisted from other jobs,” Sauvé said.

Flu Surveillance

The CDC assesses the current bird flu situation as a low public health risk because the country’s flu surveillance system hasn’t flagged troubling alerts.

The system scans for abnormal increases in hospital visits. Nothing odd has turned up there. It also analyzes a subset of patient samples for unusual types of flu viruses. Since late February, the agency has assessed about 36,000 samples. No bird flu.

However, Samuel Scarpino, an epidemiologist who special-

izes in disease surveillance, said this system would miss many emerging health threats because, by definition, they start with a relatively small number of infections. Roughly 200,000 people work on farms with livestock in the United States, according to the CDC. That’s a mere 0.1% of the country’s population.

Scarpino said the CDC’s surveillance would be triggered if people started dying from the bird flu. The 13 known cases have been mild. And the system will probably pick up surges if the virus spreads beyond farmworkers and their closest contacts — but by then it may be too late to contain.

“We don’t want to find ourselves in another COVID situation,” Scarpino said, recalling how schools, restaurants, and businesses needed to close because the coronavirus was too widespread to control through testing and targeted, individual isolation. “By the time we were catching cases,” he said, “there were so many that we were only left with bad options.”

Troubling Signs

Researchers warn that the H5N1 bird flu virus has evolved to be more infectious to mammals, including humans, in the past couple of years. This drives home the need to keep an eye on what’s happening as the outbreak spreads to dairy farms across the country.

The bird flu virus appears be spreading mainly through milk and milking equipment. But for the first time, researchers reported in May and July that it spread inefficiently through the air between a few laboratory ferrets kept inches apart. And in cattle experiments, some cows were infected by breathing in virus-laden microscopic droplets — the sort of thing that could happen if an infected cow was coughing in close proximity to another.

Cows do, in fact, cough. The new study from Texas notes that cattle coughed during outbreaks on the farms and showed other signs of respiratory illness.

Other observations were ominous: About half of some 40 cats on one farm died suddenly at the peak of its outbreak, probably from lapping up raw milk suffused with bird flu virus. Most people diagnosed with the bird flu have been infected from animals. In his new study, Gray saw a hint that the virus may occasionally spread from person to person, but he added that this remains conjecture. One of the two people who had antibodies worked in the farm’s cafeteria adjacent to the milking parlor — alongside farmworkers but not cattle.

“We need to find ways to have better surveillance,” he said, “so we can make informed decisions rather than decisions based on guesswork.”

Amy Maxmen is a public health local editor and correspondent for KFF Health News, which produced this article. She covers efforts to prevent disease and improve wellbeing outside of the medical system, and the obstacles that stand in the way.

REFERRALS/PRIOR

VIRTUAL

Never

VIRTUAL

California Speeds Up Indoor Heat Protections Amid Sweltering Weather

By Samantha Young

CALIFORNIANS WORKING INDOORS ARE getting immediate protections from extreme heat as much of the state baked in triple-digit temperatures this summer.

California has had heat standards on the books for outdoor workers since 2005, but the state announced Wednesday that a set of rules for indoor workers had been finalized following an expedited review. The state’s Occupational Safety and Health Standards Board approved the regulation last month, but it needed to be vetted for legal compliance.

“This regulation provides protections for workers across California and helps prepare employers to deal with the challenges of rising temperatures in indoor environments,” said Debra Lee, chief of California’s Division of Occupational Safety and Health.

California is among a few states responding to the growing impacts of climate change and extreme heat with worker safety standards. Earlier this month, the Biden administration proposed federal rules to protect indoor and outdoor workers from heat exposure as extreme heat, already the No. 1 weather-related killer in the U.S., becomes even more dangerous.

California’s standards require indoor workplaces to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear

protective clothing or are exposed to radiant heat, such as furnaces. Worksites that don’t have air conditioning may use fans, misters, and other methods to bring the room temperature down.

The rules allow workarounds for businesses if they can’t cool their workplaces sufficiently. In those cases, employers must provide workers with water, breaks, areas where they can cool down, cooling vests, or other means to keep them from overheating.

But even with workarounds, businesses are concerned about the cost of complying with the regulation, especially small businesses that don’t own their storefronts or are in old buildings, said Robert Moutrie, a senior policy advocate at the California Chamber of Commerce.

“The simplest answer to this regulation is AC, and that’s a costly investment,” Moutrie said. “If you’re a small business and you don’t own your structure, you can’t make changes like creating a new space to cool down.”

The rules have been in development since 2016 — delayed, in part, because of the COVID pandemic. The worker safety board requested the regulations be expedited. A standard review would have delayed the regulation taking effect until the fall, leaving workers largely unprotected from the summer heat.

The regulation applies to most indoor workplaces, including classrooms and even delivery vehicles. But state regulators exempted prisons and local correctional facilities after Gov. Gavin Newsom’s administration projected it could cost the California Department of Corrections and Rehabilitation billions of dollars to implement.

The board intends to draft a separate regulation for the tens of thousands of workers at the state’s 33 state prisons, conservation camps, and local jails. That could take a year, if not longer.

In 2021, the Department of Health and Human Services reported, 1,602 heat-related deaths occurred nationally, which is likely an undercount because healthcare providers are not required to report them. In 2023, HHS reported, 2,302 heat-related deaths occurred. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

Meanwhile, global temperatures in June were a record high for the 13th straight month.

“This is really one of the biggest safety issues we see workers experiencing across California in many different industries,” said Tim Shadix, legal director at the Warehouse Worker Resource Center, which lobbied for the protections.

“And the problem is only getting worse with climate change and hotter summers.”

Samantha Young is a senior correspondent for KFF Health News, which produced this article, where she covers healthcare politics and policy in California, focusing on government accountability and industry influence.

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PRACTICE ANNOUNCEMENTS

VIRTUAL SPEECH THERAPY AVAILABLE: Accepting new pediatrics and adult patients. We accept FSA/HSA, private pay, Medicare, Medi-Cal, and several commercial insurance plans pending credentialing. Visit virtualspeechtherapyllc.org or call 888-855-1309.

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

COUNTY OF SAN DIEGO DEPUTY CHIEF ADMINISTRATIVE OFFICER! Salary: $280,000-$300,000 Annually. The County of San Diego is thrilled to announce unique openings for Deputy Chief Administrative Officers (DCAOs) across our four County Groups: Finance and General Government Group (FGG), Health & Human Services Agency (HHSA), Land Use and Environment Group (LUEG), and the Public Safety Group (PSG). With a new Chief Administrative Officer (CAO) at the helm, the County is in an extraordinary period of transformation and opportunity. The DCAOs will direct, organize and oversee all activities within their designated Group. Additionally, the DCAOs aid the CAO in the coordination of county operations, program planning, development, and implementation. The DCAOs must demonstrate strong leadership and model our core values of integrity, belonging, equity, excellence, access, and sustainability. How To Apply: Take this opportunity to make a significant impact and drive positive change in our community. Apply now by submitting your application here: Deputy Chief Administrative Officer-24210407U Key Dates: Resume Review: Week of August 5th; Community Panel Interviews: Week of August 19; Final Interviews: Week of September 3rd; Expected Start Dates: Month of October

COUNTY OF SAN DIEGO PROBATION DEPT. MEDICAL DIRECTOR: The County of San Diego is seeking dynamic physician leaders with a passion for building healthy communities. This is an exceptional opportunity for a California licensed, Board-certified, physician to help transform our continuum of care and lead essential medical initiatives within the County’s Probation Department. Anticipated Hiring Range: Depends on Qualifications Full Salary Range: $181,417.60–$297,960.00 Annually COUNTY OF SAN DIEGO As part of the Probation Administrative team, the Medical Director is responsible for the clinical oversight and leadership of daily operations amongst Probation facilities’ correctional healthcare programs and services. As the Medical Director, you will have significant responsibilities for formulating and implementing medical policies, protocols, and procedures for the Probation Department. (sandiegocounty.gov)

PART-TIME CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to Dr. Keith Brady at uabresearchdoc@yahoo.com

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 PHYSICIAN: 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.

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) 2060988 or email dasnarla@gmail.com

OFFICE SPACE / REAL ESTATE AVAILABLE

LA JOLLA/XIMED OFFICE TO SUBLEASE: Modern upscale office on the campus of Scripps Hospital — part or full time. Can accommodate any specialty. Multiple days per week and full use of the office is available. If interested please email kochariann@yahoo.com or call (818) 319-5139.

SUBLEASE AVAILABLE: Sublease available in modern, upscale Medical Office Building equidistant from Scripps and Sharp CV. Ample free parking. Class A+ office space/ medical use with high-end updates. A unique opportunity for Specialist to expand reach into the South Bay area without breaking the bank. Specialists can be accommodated in this first floor high-end turnkey office consisting of 1670 sq ft. Located in South Bay near Interstate 805. Half day or full day/week available. South Bay is the fastest growing area of San Diego. Successful sublease candidates will qualify to participate in ongoing exclusive quarterly networking events in the area. Call Alicia, 619-585-0476.

OFFICE SPACE FOR SUBLEASE – SOUTHEAST SAN DIEGO: 3 patient exam rooms, nurse’s station, large reception area and waiting room. Large parking lot with valet on-site, and nearby bus stop. 286 Euclid Ave - Suite 205, San Diego, CA 92104. Please contact Dr. Kofi D. SefaBoakye’s office manager: Agnes Loonie at (619) 435-0041 or ams66000@aol.com

MEDICAL OFFICE FOR SALE OR SUBLEASE: A newly remodeled and fully built-out primary care clinic in a highly visible Medical Mall on Mira Mesa Blvd. at corner of Camino Ruiz. The office is approximately 1,000 sq ft with 2 fully equipped exam rooms, 1 office, 1 nurse station, spacious and welcoming waiting room, spacious reception area, and ADA accessible restroom. All the furniture and equipment are new and modern design. Ample parking. Perfect for primary care or any specialty clinic. Please contact Nox at 619-776-5295 or noxwins@hotmail.com. Available immediately.

EL CAJON – RENOVATED MEDICAL OFFICE AVAILABLE: Recently renovated, turnkey medical office in freestanding single-story unit available in El Cajon. Seven exam rooms, spacious waiting area with floor-to-ceiling windows, staff break room, doctor’s private office, multiple admin areas, manager’s office all in lovely, droughtresistant garden setting. Ample free patient parking with close access to freeways and Sharp Grossmont and Alvarado Hospitals. Safe and secure with round-the-clock monitored property, patrol, and cameras. Available March 1st. Call 24/7 on-call property manager Michelle at the Avocado Professional Center (619) 916-8393 or email help@avocadoprofessionalcenter.com.

OPERATING ROOM FOR RENT: State of the Art AAAASF Certified Operating Rooms for Rent at Outpatient Surgery of Sorrento. 5445 Oberlin Drive, San Diego 92121. Ideally located and newly built 5 star facility located with easy freeway access in the heart of San Diego in Sorrento Mesa. Facility includes two operating rooms and two recovery bays, waiting area, State of the Art UPC02 Laser, Endoscopic Equipment with easy parking. Ideal for cosmetic surgery. Competitive Rates. Call Cyndy for more information 858.658.0595 or email Cyndy@roydavidmd.com.

PRIME LOCATION – MEDICAL BUILDING LEASE OR OWN OPPORTUNITY IN LA MESA: Extraordinary opportunity to lease or lease-to-own a highly visible, freewayoriented medical building in La Mesa, on Interstate 8 at the 70th Street on-ramp. Immaculate 2-story, 7.5k square foot property with elevator and ample free on-site parking (45 spaces). Already built out and equipped with MRI/CAT machine. Easy access to both Alvarado and Sharp Grossmont Hospitals, SDSU, restaurants, and walking distance to 70th St Trolley Station. Perfect for owner-user or investor. Please contact Tracy Giordano [Coldwell Banker West, DRE# 02052571] for more information, (619) 987-5498.

POWAY MEDICAL OFFICE SPACE FOR LEASE

2/1/2024: Fully built out, turnkey 1,257 sq ft ADA-compliant suite for lease. Great location in Pomerado Medical/ Dental Building, next to Palomar Med Center Poway campus. Building restricted to medical/allied health/dental practices, currently houses ~26 suites. Ideal for small health practice as primary or satellite location. Lease includes front lobby, reception area, restrooms, large treatment area, private treatment/exam rooms. Located on second floor, elevator/stair access. Bright, natural lighting; unobstructed views of foothills. On-site parking; nearby bus service. Flexible lease terms available from 3-5 years at fair market rate. Contact Debbie Summers at debjsummers3@gmail.com (858) 382-8127.

KEARNY MESA OFFICE TO SUBLEASE/SHARE: 5643

Copley Dr., Suite 300, San Diego, CA 92111. Perfectly centrally situated within San Diego County. Equidistant to flagship hospitals of Sharp and Scripps healthcare systems. Ample free parking. Newly constructed Class A+ medical office space/medical use building. 12 exam rooms per half day available for use at fair market value rates. Basic communal medical supplies available for use (including splint/cast materials). Injectable medications and durable medical equipment (DME) and all staff to be supplied by individual physicians’ practices. 1 large exam room doubles as a minor procedure room. Ample waiting room area. In office x-ray with additional waiting area outside of the x-ray room. Orthopedic surgery centric office space. Includes access to a kitchenette/indoor break room, exterior break room and private physician workspace. Open to other MSK physician specialties and subspecialties. Building occupancy includes specialty physicians, physical therapy/occupational therapy (2nd floor), urgent care, and 5 OR ambulatory surgery center (1st floor). For inquiries contact kdowning79@gmail.com and mgamboa@ortho1.com for more information. Available for occupancy projected as February 2024.

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.

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 reception. 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.

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 RESEARCH SCIENTISTS: (non-tenured, Assistant, Associate or Full level): The University of California, San Diego campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd.edu/ORU/index.html are conducting an open search. Research Scientists are extramurally funded, academic researchers who develop and lead independent creative research programs similar to Ladder Rank Professors. They are expected to serve as principal investigators on extramural grants, generate high caliber publications and research products, engage in university and public service, continuously demonstrate independent, high quality, significant research activity and scholarly reputation. Appointments and duration vary depending on the length of the research project and availability of funding. https://apol-recruit.ucsd.edu/JPF03713

PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research and Innovation 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://apolrecruit.ucsd.edu/JPF03712/apply