Addiction Medicine by mo-afp

FP FALL 2021

MISSOURI FAMILY PHYSICIAN VOLUME 40, ISSUE 4

Addiction Medicine

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

CONTENTS

BOARD CHAIR Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT-ELECT John Burroughs, MD (Liberty) VICE PRESIDENT Kara Mayes, MD (St. Louis) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

4 The Addiction Issue

BOARD OF DIRECTORS

8 The Addiction Pandemic

DIRECTOR Arihant Jain, MD (Cameron) ALTERNATE Mike Feuerbacher, MD (Maryville) DIRECTOR Vacant ALTERNATE Vacant DIRECTOR Emily Doucette, MD, FAAFP (St. Louis) DIRECTOR Dawn Davis, MD (St. Louis) ALTERNATE Lauren Wilfling, MD (St. Louis) DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald) ALTERNATE Jennifer Allen, MD (Hermann) DIRECTOR Natalie Long, MD (Columbia) ALTERNATE Amanda Shipp, MD (Versailles) DIRECTOR David Pulliam, DO, FAAFP (Higginsville) ALTERNATE Justin Cramer, MD, FAAFP (Marshall) DIRECTOR Beth Rosemergey, DO, FAAFP (Kansas City) DIRECTOR Afsheen Patel, MD (Kansas City) ALTERNATE Wael Mourad, MD, FAAFP (Kansas City) DIRECTOR Andi Selby, DO (Joplin) ALTERNATE Barbara Miller, MD (Buffalo) DIRECTOR Douglas Crase, MD (Licking) ALTERNATE Vacant DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau) ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Lees Summit) Josephine Glaser, MD (St. Louis) Krishna Syamala, MD (St. Louis)

DISTRICT 1 DISTRICT 2 DISTRICT 3 DISTRICT 4 DISTRICT 5 DISTRICT 6 DISTRICT 7 DISTRICT 8 DISTRICT 9 DISTRICT 10

RESIDENT DIRECTORS Morgan Murray, MD, UMKC Wesley Goodrich, MD, UMKC (Alternate)

STUDENT DIRECTORS Kelly Dougherty, UMC Karstan Luchini, KCU Joplin (Alternate)

AAFP DELEGATES Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

6 Annual Fall Meeting Notice

11 PDMP: Why Is It Taking So Long? 12 Combatting the Opioid Epidemic: A Concise Review of Buprenorphine in Treating Opioid Use Disorders 15 Addiction and the Family Dynamic 17 Chronicles of the 2021 Summer Externs 21 MAFP’s Transition to Practice Conference Inspires Students and Residents 23 New Resident and Student Leadership 24 Members in the News 26 References 27 Residency Composites

MARK YOUR CALENDAR October 17 Virtual KSA: Health Counseling & Preventive Care November 12-13 29th Annual Fall Conference and Annual Business Meeting Big Cedar Lodge — More info on pages 6 & 7 December 12 Virtual KSA: Diabetes February 28-March 1, 2022 Advocacy Day More info on page 35

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org MO-AFP.ORG 3

The Addiction Issue

saw a longtime patient, William, yesterday in my office who has been battling alcoholism for many years. He is finally in a good place but remains fearful of relapse. It’s as if he feels like he is doomed for failure as he has relapsed so many times in the past. He has support structures in place, but still feels it is inevitable that he will “fall off the wagon again.” Reassurance provides some Jamie Ulbrich, MD, FAAFP comfort and the fact that if and when it happens, Board Chair, Marshall he knows he can come back and I will still love and support him through his recovery again. William’s story of addiction is familiar to most of us as it is a disorder we see in our patients almost every day. Outside of our clinics, many of us have experienced addiction through friends and family. Some readers of this have even battled addiction personally. We strive day in and day out to deliver the best care we can to our patients. Addiction is one of those disorders that has a heavy bearing on every part of a person’s health physically, emotionally, and certainly relationally. In this issue, we explore several facets of addiction. It is my most sincere hope that you will learn something from the perspectives of our authors and use the information to deliver better care to your patients. Remember, we, along with our patients, are each on a life journey. It is our

Mission Statement:

calling to help our patients through this journey with empathy, love, guidance, and support. My time as Board Chairman is concluding. I would like to take this opportunity to say thank you to the MAFP membership for allowing me the opportunity to serve you through various leadership positions. As I reflect on my time with the MAFP, I feel thankful to have met and developed relationships with so many people across the state of Missouri. As with our training in medical school and residency, I am grateful to those that have gone before me and have tried to follow their example. We have been so blessed to have great leadership in Jefferson City with Kathy Pabst and Bill Plank. They have a strong vision and have been so supportive of our Academy. I can tell you they work tirelessly “behind the scenes” every day (and night) to make sure everything runs smoothly. Lastly, my hope and prayer are that you would take some time to count the blessings you have been given and remember what a privilege it is to care for the people you have been entrusted with. God Bless!

The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.

MISSOURI FAMILY PHYSICIAN October - December 2021

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Annual Meeting Notice: November 13, 2021 You are invited to the Missouri Academy of Family Physicians Annual meeting held in conjunction with the 29th Annual Fall Conference. The meeting will be on November 13th from 11:45 a.m. – 1:45 p.m. at Big Cedar Lodge in Ridgedale, MO. This meeting is open to all members. The agenda for this meeting will include annual reports from the MAFP officers, election of the 2021-22 slate of officers, 6

MISSOURI FAMILY PHYSICIAN October - December 2021

proposed bylaws changes, and the annual awards and installation ceremony. More information about the meeting can be found on the website at: https://www. mo-afp.org/members-only/. For more information about the Annual Fall Conference, please visit www.mo-afp. org/cme-events/afc.

Events held at Grandview Conference Center All CME Sessions in Salon A-C Check in early on Thursday, November 11, from 4:00-6:00 pm!

Friday, November 12, 2021

Saturday, November 13, 2021

7:00 - 8:00 am

Registration and Breakfast with Exhibitors Exhibit Hall, Salon D

7:00 - 8:00 am

Registration and Breakfast with Exhibitors Exhibit Hall, Salon D

7:00 - 10:45 am

Exhibit Hall Open

7:00 - 10:45 am

Exhibit Hall Open

8:00 - 9:00 am

Management of Hyperlipidemia in the Family Medicine Setting: Diagnosis, Management and the Role of Emerging Lipid-lowering Therapies Paul Ziajka, MD, PhD

7:00 - 8:00 am

Walk with a Doc Walk (Non-CME) Katie Davenport-Kabonic, DO Meet in Grandview Conference Center Lobby

9:00 - 10:00 am

Pre-registered participants receive a free t-shirt

Sponsored by PeerView

Sunday, November 14, 2021 8:00 - 9:30 am

Breakfast and Commission Meetings

9:30 am - 12:00 pm Board Meeting MO-AFP.ORG 7

The Addiction Pandemic

Kurt Bravata, MD, FASAM Citizens Memorial Hospital Bolivar, MO

he COVID-19 pandemic has wreaked havoc on mental and physical health globally. I have seen this firsthand in my patient population where I practice in rural Southwest Missouri. From my family medicine clinic and the nursing home, to the addiction clinic, my patients have suffered physically and mentally. We have seen an increase in unemployment, morbidity and mortality, hopelessness, and yes, addiction. Currently, our addiction recovery visits are up 53% compared to this time last year and we have already seen as many unique patients in half a year as we encountered all last year. According to preliminary figures released earlier this month by the Centers for Disease Control and Prevention, synthetic opioid fatalities rose by an unprecedented 55% during the twelve months ending in September 2020. That represents a drastic increase in overdoses that left more than 90,000 Americans dead during the 12-month period ending in September 2020, according to the latest data. Deaths from methamphetamines and other stimulants

MISSOURI FAMILY PHYSICIAN October - December 2021

also surged by roughly 46%, an increase Nora Volkow, head of the National Institute on Drug Abuse, (ASAM) said is linked to fentanyl contamination. The issue is certainly not limited to my area as the impact of addictions and overdoses is being addressed nationally in Washington D.C. I have had the distinct pleasure to work with Senator Roy Blunt on establishing national programs. In asking him about measures being implemented in Washington, he said, “The COVID-19 pandemic has exacerbated a gap in America’s medical system that we have warned about for years: the lack of access to mental and behavioral health care. Increased incidence of depression and anxiety, combined with limited access to in-person counseling and meetings, created a perfect storm for a mental health crisis in our country. Drug overdose deaths increased by 30% between October 2019 and October 2020. Making sure people are able to get the help they need is more critical than ever. Working to improve access to mental health care and addiction treatment has

been one of my top priorities in Congress. In 2014, I worked with Sen. Debbie Stabenow (Mich.) to pass the Excellence in Mental Health Act, which established the first Certified Community Behavioral Health Clinics in eight states, including Missouri. These clinics increase access to community-based treatment, getting people care faster and closer to home, and reducing hospitalizations and emergency room visits. We’ve been able to point to the success of the program in our state to secure additional funding for startup grants across the country, establishing clinics in more than 300 communities in 40+ states. Serving on the Senate appropriations subcommittee that funds health programs, we have also worked in a bipartisan way to increase funding for opioid-related programs by more than 1200%. We increased funding for the State Opioid Response Grant program and, in last year’s bill, provided additional flexibility to states by allowing them to use grant dollars to address stimulants.

I’m grateful for the work health care providers are doing around the clock to reach patients throughout this pandemic. I will continue doing my part to make sure we have the resources in place to support their efforts by expanding the Excellence program and ensuring addiction treatment

and prevention programs are funded at the level commensurate with the challenge we face." Volkow said in an interview that fentanyl has so thoroughly infiltrated the illegal drug supply that 70 percent of cocaine overdose deaths and 50 percent of methamphetamine overdose deaths also involved fentanyl. In many cases, she said, users are unaware that their drugs are laced with the powerful painkiller, which can halt breathing even if a minute amount is ingested. In other cases, users knowingly take multiple drugs. “Most of the deaths are from multiple drugs,” she said. There are many reasons for this uptick in patients seeking addiction help. Among them is the fact that many more individuals are working from home or taking unemployment, which is causing more down time either alone (often exacerbating self-medicating behavior), or with spouses and/or other family members, resulting in increased awareness of the substance abuse issues that their loved ones are suffering from. Additionally, many patients who were already enrolled in our addiction recovery program experienced relapses as a result of increased psychosocial stressors. The COVID-19 pandemic and MO-AFP.ORG 9

the resulting economic recession have negatively affected many people’s mental health and created new barriers for people already suffering from mental illness and substance use disorders. During the pandemic, about 4 in 10 adults in the U.S. have reported symptoms of anxiety or depressive disorder, a share that has been largely consistent, up from one in ten adults who reported these symptoms from January to June 2019 (Figure 1). A KFF Health Tracking Poll from July 2020 also found that many adults are reporting specific negative impacts on their mental health and well-being, such as difficulty sleeping (36%) or eating (32%), increases in alcohol consumption or substance use (12%),

and worsening chronic conditions (12%), due to worry and stress over the coronavirus. As the pandemic wears on, ongoing and necessary public health measures expose many people to experiencing situations linked to poor mental health outcomes, such as isolation and job loss. This increased growth in our program has required us to seek the assistance of additional staff to help meet the needs of our patient population. For patients who are not able to make it to our facility for a face-to-face encounter, last year’s regulation changes have allowed us to treat them via phone call or telemedicine visit. This has been a real game changer, especially when it comes to follow-up encounters. One of the things that has been astounding to me is that many patients who are hesitant to take the COVID-19 vaccine are willing to smoke or ingest substances that they know are harmful. I have pondered this phenomenon and come to the following conclusions: first, that for some individuals, the desire for temporary pleasure is a stronger motivator then the promise of long-term health. Second that humans are often willing to accept known risks, rather than what they perceive to be unknown risks (“the devil you know”, so to speak), and finally despite living in an age of unprecedented information access, there is a gap when it comes to clear unified messaging and the type of trust-inducing education that affects meaningful change. I have seen this phenomenon in my chronic care patients, some with multiple comorbidities, such as uncontrolled diabetics, COPD, and heart disease. Sadly, sometimes despite my best efforts, such 10

MISSOURI FAMILY PHYSICIAN October - December 2021

patients will continue to smoke cigarettes, abuse alcohol, and eat unhealthy diets, because they value the momentary satisfaction they experience more than the health benefits which their medical providers have proposed could be achieved through long-term lifestyle modification. It often takes a traumatic life threatening event such as diabetic ketoacidosis, respiratory failure, or a heart attack to get such resistant patients to begin the process of positive change. For the addicted patient, it sometimes requires incarceration, loss of a loved one, an overdose, or the fear of not being able to get their children back from family services to cause them to seek addiction recovery care. Whatever the reason is that a patient comes in for addiction treatment, it is a self-evident fact that the motivated patient has a much higher chance of success than one who is resistant to change. As they say, “You can lead a horse to water but you cannot make them drink”. One of the things I love about addiction recovery is the dynamic shift that occurs in the doctor-patient relationship once the word is out that your program is a judgement free zone where patients can freely talk about their substance abuse history, current struggles, and relapses without fear of losing their relationship with their medical provider. Patients who otherwise might not seek medical care start to show up to the office. Before long, they are sharing their difficult stories with a level of honesty that they previously were not used to employing. Eventually, after the substance abuse issues have been adequately treated and are no longer the driving force in these patients’ lives, they are able to focus on the physical and mental health issues that many of them have been ignoring for years. It is so important to set clear expectations with your patients early on, letting them know that the only way to adequately and effectively treat them is for there to be a clear and open bidirectional line of communication between doctor and patient. As a physician it can be difficult hearing details of the drama and trauma that so many of these patients experience on a day-to-day basis and it takes a practiced tolerant patience to be a listening ear and the metaphorical shoulder they can cry on if needed. For some patients, their addiction provider is the only person they feel comfortable opening up to and they may never feel safe doing so with a counselor or psychiatrist. This hesitancy and suspicion may be the result of past negative experiences with healthcare providers or due to general trust issues from years of being burned by relationships. As family physicians, we have a unique opportunity to make our clinics the point-of-care access sites for the addiction recovery services that many of our patients so desperately need but are often hesitant to seek. Through appropriate screening and compassionate care we can identify and treat patients suffering from addiction or refer them to a higher level of service when indicated. References found on page 26

Brian Bernskoetter

MAFP Governmental Consultant

PDMP: Why Is It Taking So Long?

fter 17 years and multiple versions of pushing for a statewide Prescription Drug Monitoring Program (PDMP), the 2021 legislative session finally saw passage in SB 63. MAFP, along with other health care organizations, has strongly supported a statewide PDMP and celebrates the passage. But what happens now? What do family physicians around Missouri need to know about the PDMP? To provide a little background refresher, SB 63, establishes the “Joint Oversight Task Force of Prescription Drug Monitoring” within the Office of Administration, and is charged with monitoring certain controlled substances. The vendor for this program will be selected through a competitive bid process, which takes time. The program will collect and maintain patient controlled substance prescription dispensation information submitted by dispensers throughout the state and the information will be retained for no more than three years. Patient information submitted will only be utilized for the provision of health care services to the patient. Prescribers, dispensers, and other health care providers will be permitted to access a patient’s information in the course of providing health care services to the patient. The patient will have access to his/her information upon request from the vendor. Information in this platform will not be provided to law enforcement or used to prevent an individual from owning or obtaining a firearm. Patient information is protected through HIPAA and legal penalties apply for disclosure of information outside the parameters of this bill. The General Assembly did not allocate funds during the 2021 session to implement the program this fiscal year. The Governor and his administration are currently reviewing options of using other resources to initiate the program, but that seems unlikely at this point. Funding could be allocated in a supplemental

budget or wait for the regular budget process. The federal government has funding available to implement programs such as this; however, the process of securing and deploying those funds can’t be completed until October 2022 at the earliest. This all means more time is needed before implementation of the bill. Once funded, the PDMP is to be located in the Office of Administration. There is a substantial amount of work to complete in order to facilitate the mechanics of the PDMP: • The Joint Oversight Task Force must be established of practitioners who are already seated on state licensing boards. There will be two physicians, two pharmacists, a dentist and a nurse practitioner. • The law requires an open bid process to contract with a vendor to manage the prescription data and reporting. • Rules to govern the PDMP must be drafted. All these tasks will take many months from the time they are started. Unfortunately, none of these processes have been initiated as of the time of the writing of this article. In addition, there are many other tasks needed to implement the PDMP such as hiring employees to plan, implement, and operate the program; apply for grants; draft and promulgate regulations; and prepare bid proposals to contract with vendors to handle the prescription data. Dispensers will begin reporting prescriptions once every 24 hours with plans in later years to move to real-time reporting. The prescription data may be queried by individual prescribers and pharmacies, but is not mandatory. Data may only be released to regulatory authorities as authorized by HIPAA. The existing St. Louis County PDMP will continue until the state has the statewide PDMP fully functional. Once the statewide program is operating, then the St. Louis County PDMP data can be transferred over to the state system. MO-AFP.ORG 11

Combatting the Opioid Epidemic:

A Concise Review of Buprenorphine in Treating Opioid Use Disorders

Matthew Starr, OMS2 Kansas City University - Joplin

Adam Holbrook, OMS2 Kansas City University - Joplin

Brad L Barlow, MD Fruitland, Idaho 12

MISSOURI FAMILY PHYSICIAN October - December 2021

s I have watched friends and family struggle with addiction, I have noticed suggestions that people with certain qualities are more prone to opioid dependency. Traits such as high pain tolerance, tough personas, and tendencies toward secrecy, recklessness, or rebelliousness are often labeled as primary predictors of becoming opioid dependent. While these factors may contribute to opioid dependency, possessing them does not mean you are likely to become an addict—nor do all addicts treated by healthcare providers possess them. When my close friend and I were kids, we decided to be adventurous one night and “camp” in our backyard. While we were playing, my friend injured his foot. He is both tough and stubborn, and thus did not show an inkling of pain. I only learned of the issue when he said, “Hey, I have to show you something.” He lifted the underside of his foot revealing a large shard of glass in a bloody wound. At this point in my life, I was not yet interested in a career in medicine and the sight of his wound made me feel sick to my stomach. All my friend said was, “Don’t tell my mom.” This illustrates a natural tendency toward rebellion and recklessness that my friend has always had despite careful, loving guidance by his parents. Unfortunately, these tendencies contributed to his substance abuse—first alcohol, marijuana, and tobacco, then to pills and on to the cheaper, more accessible drug: heroin. My experiences with my friend have prompted me to take a personal interest in understanding opioid dependency and how to treat it, driving me to choose this topic as the focus of my current research. While the legal system has its own tools for rehabilitating individuals like my friend—those struggling with opioid use disorders (OUDs)—it cannot do so without working hand in hand with medical practitioners. Buprenorphine, often combined with naloxone, is a powerful tool for a physician to help rehabilitate patients with OUDs who have an illness beyond their control; however, its potential for abuse demands that physicians should be informed of its benefits, indications for use, risks, and the certifications required for prescription before deciding if it is right for their daily practice.

Pharmacology, Benefits, and Indications

The Need From 1999-2019, nearly half a million people died from drug overdoses involving opioids1. The origin of this crisis is a wellknown dilemma for physicians, especially those involved in primary care: it is estimated that approximately 36.1 million Americans experience daily pain, but in 2016 alone more than 11.5 million adults 12 and older reported prescription opioid misuse2. The balance between beneficence and non-maleficence places physicians in a moral and ethical dilemma of prescribing potentially addictive and harmful medication or offering less effective analgesic alternatives. Those who misuse prescription opioids and become addicted often resort to cheaper yet unregulated and more deadly alternatives like heroin. While researchers struggle to find safer, abuse-deterrent opioids and other alternatives for acute and chronic pain management, it is important for providers to know how to both treat overdoses (via naloxone) and how to prevent them using addiction management medications such as methadone and buprenorphine. Research indicates methadone to be preferential in treating addiction cravings in illicit opioid users due to their tendency to drop out of treatment when prescribed other alternatives. In contrast, buprenorphine-naloxone is preferred over methadone for stable oral prescription opioid users. However, it should be noted that buprenorphine-naloxone is generally considered to be safer than both methadone⁴ and medical withdrawal treatment options5. Some addiction medicine specialists state that buprenorphine is quickly becoming preferred to methadone for office-based opioid treatment (OBOT).

Buprenorphine is a partial µ-receptor agonist and a complete kappa-receptor antagonist, though its effects are unknown and suggested to be minimal. Its affinity for µ-receptors is significantly higher than that of hydromorphone, morphine, fentanyl, and oxycodone, making it an effective competitive inhibitor for those other compounds. It also has slow dissociation kinetics, meaning that it adheres to its target receptors longer than other opioids before detaching, with a half-life of 24-42 hours. Buprenorphine can therefore be used on daily or less-than-daily prescription schedules5. These unique features make buprenorphine a great target for the prevention of withdrawal symptoms in individuals who are recovering from addiction to opioids. Studies have shown that buprenorphine or methadone treatment are far more effective in treating opioid addiction than abstinence-based treatments alone. Buprenorphine is easy to access, especially for rural areas that may not have access to methadone4. It has even been suggested as a potential tool for emergency use by prehospital providers such as EMS professionals11. When compared to methadone, buprenorphine is also less likely to lead to overdoses due to misuse4. It is therefore indicated as an effective, long-term treatment for opioid disorder for patients with an opioid use disorder who can be monitored during treatment and are in an adequate state of withdrawal6. Buprenorphine is often combined with naloxone (which is administered parenterally) to precipitate a state of opioid withdrawal. The overall effectiveness of buprenorphine being used as a long-term treatment for opioid disorders was evaluated in a meta-analysis of 31 randomized trials up to 2013. This analysis revealed that buprenorphine was more effective than both medical withdrawal treatment and methadone in reducing relapse rate7.

Risks and Misconceptions

One of the primary apprehensions in prescribing an opioid compound like buprenorphine to a patient with an opioid use disorder is the risk of overdose. One study collected retrospective data on opioid overdose deaths in Rhode Island, analyzing the toxicology reports. They found that of 534 opioid-involved deaths between 2016-2018, only 5.4 percent had buprenorphine in their blood, and each of those cases had co-exposures8. As discussed, buprenorphine is a partial opioid agonist with higher affinity than many of its opioid counterparts, making it effective at competitively inhibiting opioid receptors. Its status as a partial opioid agonist means that it will also mimic the symptoms caused by full opioid agonists, including respiratory depression, though its effects are limited. Furthermore, because the µ-receptors have a higher affinity for buprenorphine, competitive inhibition protects the patient from the effects of overdose of other compounds like heroin or fentanyl. Thus, the danger of overdose realistically lies in the discontinuation of buprenorphine and loss of its protection should the patient subsequently consume stronger, full opioid agonists7. Other general side effects of buprenorphine resemble that of other opioid receptor agonists though they are significantly less severe. MO-AFP.ORG 13

Physicians should warn their patients about the danger of overdose should they choose to discontinue treatment. It is also recommended to warn patients about the interactions buprenorphine has with CNS depressants such as alcohol and muscle reactants, a combination that can lead to increased intoxication and overdose7. Specifically, buprenorphine is metabolized by the P450 system (CYP3A4, specifically) and thus interacts with many drugs which are metabolized by the same pathway, leading to the accumulation of adverse drug metabolites9. Physicians who fear they are helping patients to “get high” by prescribing an alternative to heroin can be reassured that intoxication only occurs if the patient takes it along with other substances or not as directed, such as to medicate withdrawal symptoms between usage of fullreceptor agonists like heroin10. Since buprenorphine is an opioid substance, physicians who are concerned that patients may sell it can monitor their patients by instituting film/pill checks and by performing urine buprenorphine tests. Another reassuring statistic is sourced from a study that reported that 64 percent of opioid users who had used buprenorphine illicitly did so because they did not have access to or could not afford proper care10, therefore indicating that illicit distribution in these cases was carried out to accomplish the main purpose of buprenorphine: treating withdrawal symptoms. The most pressing concern with buprenorphine (along with methadone) is that treatment retention rates are low; trials have shown them to be at 50 percent or less at six months7. Even in combination with counseling and proper patient management, patients are more likely to drop from treatment than finish it, opening the possibility for relapse and overdose of illicit opioid substances. An analysis of current evidence does suggest that aggressive dosing and dose escalation are likely to be helpful, as well as some behavioral treatments known as contingency management, which includes rewarding treatment attendance or including loved ones in the treatment plan. However, treatment retention is a problem that requires further research and which should be monitored closely by any practitioners prescribing buprenorphine in the future7.

How to Use Buprenorphine: Certifications and Dosing

Buprenorphine is typically administered as a pill or a film, both of which may be split to achieve desired dosing if necessary. Dosing is suggested to start at 4-8 mg daily with titration up to 8-24 mg per day. Patients are required to be in a moderate state of withdrawal (as determined by the COWS scale) before starting, which typically takes 12-24 hours following the last opioid use7. For more specific dosing information, physicians interested in prescribing buprenorphine should refer to local addiction medicine specialists or pharmacists familiar with this prescription. As previously stated, it is important to allow withdrawal status before beginning buprenorphine. This is to avoid precipitated withdrawal in which this high-affinity, partial agonist receptor agonist removes full agonists from those receptors too quickly, resulting in a net drop in agonist effects and subsequent symptoms of withdrawal7. It is also critical to inform the patient of potential side effects and explain the dangers of overdosing should the patient decide to discontinue their use of buprenorphine. In addition to buprenorphine, physicians should advocate for nonpharmaceutical treatment such as counseling, drug testing, and 14

MISSOURI FAMILY PHYSICIAN October - December 2021

social support6. Allowing addicts to have structure and accountability in their treatment plan is critical, especially in reducing the risk of treatment dropout. I have witnessed this personally as my friend did exponentially better under a government program—drug court—which included mandatory counseling and routine drug testing with failure to meet these standards resulting in further prosecution. It should be noted that buprenorphine was originally developed as a chronic pain analgesic. Alone, or combined with naloxone, it has been shown to reduce chronic pain in patients who are currently experiencing opioid dependence. Its effect on treating chronic pain in those without opioid dependence has been shown to be less effective. Buprenorphine treatment for chronic pain in opioid-dependent pregnant women has also been investigated and is being considered for use as an alternative to methadone9. Finally, physicians who wish to prescribe buprenorphine to patients should know that it is a Schedule III medication, requiring practitioners to obtain a special waiver by completing a required course either online or in person when prescribing to large amounts of patients. More information about obtaining this certification can be found with your hospital system or by visiting SAMHSA. gov. Note that previous guidelines required providers to complete this course before prescribing buprenorphine to up to 30 patients per year, though the newly liberalized certification requirements removed the standard eight-hour DATA 2000 waiver training for the first 30 patients3, 12. Providers who wish to provide buprenorphine to more than 30 patients per year will have to pursue certification via training3.

Conclusion

The opioid epidemic is a major threat to the public health of the United States. Medical researchers, physicians, counselors, and the legal system are struggling to find a permanent solution to the problem. While the search continues, buprenorphine is a useful tool for physicians to have in their armory to help those who are currently struggling with OUDs. This article is intended to be a review of current literature on buprenorphine use—the evidence is clear that buprenorphine is an excellent candidate for treating patients with OUDs. Interested readers are encouraged to conduct further research before deciding whether to prescribe it. More effective, more accessible, and safer than medical withdrawal treatments or methadone, buprenorphine affords patients like my friend the opportunity to stifle the painful withdrawal symptoms due to opioid use and take advantage of nonpharmaceutical resources to seek sobriety.

More Information

Physicians interested in finding more information about buprenorphine can consult the following resources: •https://www.samhsa.gov/medication-assisted-treatment/ become-buprenorphine-waivered-practitioner •https://www.asam.org/advocacy/practice-resources/ buprenorphine-waiver-management •https://www.asam.org/Quality-Science/quality/2020national-practice-guideline •https://www.asam.org/Quality-Science/quality/npg/pocketguide-and-app • h t t p s : / / w w w. a a f p . o r g / n e w s / h e a l t h - o f - t h e public/20210209oudmanual.html

Addiction and the Family Dynamic: What Physicians May Need to Consider

Salley E. Gibson, MS, LPC, NCC

Amanda Mays, MA, LMFT

nyone who has struggled with substance use, or who loves someone who has struggled with substance use, will tell you that addiction affects everyone in the victim’s life. The complications and stress are a shared experience, as is recovery. A person’s family can play a critical role in overcoming substance use. As physicians, it’s important to be aware of and communicate the role families play in the addiction and recovery process. Two leaders at Burrell Behavioral Health, Missouri’s second largest Community Mental Health Center, have answered a few questions about addiction and how it affects families – and how families can hold the key to successful recovery.

Q. How does addiction affect the family dynamics (roles, systems, etc.) of patients and their loved ones? A. Trust is eroded due to many factors, which can include using money for substances and hiding it, taking advantage of loved ones, not meeting responsibilities due to substance use, making high risk decisions that affect the family and more. Stress is increased and children are impacted. Family roles can get confused as children may be taking care of a parent. There could be general confusion as patients may hide their use while other family members try to figure out what is going on. An article in Psychology Today (May 2, 2016) uses the analogy of a mobile hanging over a baby crib. All is in balance when it’s working well; each piece has a role and is part

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of that balance. But if you remove one piece (i.e., the identified patient not being responsible for their role), the mobile gets out of balance and will not work well. If the identified patient does not resume their role, another family member has to step in and take over. This adds stress to the family.

but cannot be filled at a pharmacy; it requires the patient to report daily to a methadone clinic to receive their medication.

A. Historically, substance misuse has been wrongly viewed and mistreated as an acute, behaviorally-centered condition. Conversely, the National Association of Addiction Treatment Providers recognizes addiction as: -- A primary & chronic disease; -- A disease centered in the brain; -- A disease with psychological and social components. As a chronic and relapsing brain disorder, addiction (or “substance use disorder,” as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is characterized by the National Institute on Drug Abuse as “compulsive drug-seeking and use despite adverse consequences.” Other helpful definitions: Substance use: Our definition is social user/recreational user and it is not causing problems in life. Misuse: As defined by the Center for Disease Control (CDC), this is the use of substances in a manner other than intended: using more than planned, greater amounts, more often and longer, or using another person’s prescription. Dependence: As defined by the CDC, this occurs when a body adjusts its normal functioning around substance use. This can also be referred to as Addiction or Substance Use Disorder.

therapy. Substance Use Disorder treatment has many levels and is not conducive to being treated in the doctor’s office. Physicians can be very helpful in MAT services, in conjunction with treatment, if they are interested in being part of the treatment team. Physicians can also be helpful in reducing stigma by helping identified patients understand the physiological effects of substance use.

Q. As a physician, what is my role in helping establish or re-establish health support systems between my patients and their family members? This may include Q. What may physicians need to know to help setting boundaries, addressing co-dependency, refamilies understand the difference between terms establishing trust, finding coping strategies, fighting like “addiction,” “substance use,” “misuse” and stigma, etc. “dependence” just to name a few? A. The best thing you can do is to refer them to treatment and

Q. What is the brain science behind addiction?

A. The National Association of Addiction Treatment Providers says “drugs are chemicals that produce euphoria and disrupt normal brain communication by tampering with the way neurons send, receive, and process signals.” Different drugs elicit different brain responses. Heroin and marijuana, for example, imitate natural neurotransmitters and trick the brain’s receptors into activating nerve cells. Other drugs, like methamphetamine and cocaine, cause a hyper-release of dopamine; the resulting surge of pleasure teaches the brain to seek these substances. Other drugs disrupt brain circuits and chemical systems that govern many key brain functions including memory, stress, and decision-making.

Q. If a patient is currently receiving Medication Assisted Treatment (MAT) for opioid-use disorder (i.e. Suboxone), what may I need to know as their physician?

A. The three primary medications used are: Methadone (a full agonist), Buprenorphine (a partial agonist), and oral Naltrexone (an antagonist; also used for alcohol). You can learn much more about the types of MAT at https://www.opiates.com/opiate-agonist/. Buprenorphine replaces opioids in a patient’s system and blocks the effects of any additional opioids taken. Naltrexone is an opioid antagonist that binds to receptors in the brain in order to fully block the effects of opioids. Methadone is an opioid agonist that bonds tightly to the body’s opioid receptors. It has the most long-lasting therapeutic effects, 16

MISSOURI FAMILY PHYSICIAN October - December 2021

Q. What types of treatments are available to patients with a substance-use disorder, and how can and should the family be involved in them?

A. There are many programs available, both privately and publically funded. An assessment will need to be done by any program to assess the level of care needed (residential support, long term/short term, outpatient, MAT, early intervention, etc.). Each program has an option of family therapy, and it is helpful for family members to learn about the science of addiction and how to help their family members and take care of themselves throughout the process. You can learn more about types of treatment programs through the National Institute on Drug Abuse at https://www. drugabuse.gov/publications/principles-drug-addiction-treatmentresearch-based-guide-third-edition/drug-addiction-treatment-inunited-states/types-treatment-programs. About Burrell Behavioral Health: Burrell Behavioral Health is the second largest behavioral health center in Missouri, working with more than 45,000 clients across 25 counties in Missouri and Arkansas. Burrell has more than 450 licensed providers offering a full continuum of care through our integrated network. In addition to a full continuum of mental health services, Burrell specializes in addiction treatment for youth and adults, including Medication Assisted Treatment, outpatient family, group and individual therapy, residential services, socialsetting detox and more. You can learn more at www.burrellcenter. com, or contact Sally Gibson, Vice President, Recovery Services, at sally.gibson@burrellcenter.com. Sally E. Gibson, MS, LPC, NCC, is Burrell’s Vice President, Recovery Services. She is a Licensed Professional Counselor in Oklahoma and Missouri, a Nationally Certified Counselor, and is approved as a LPC Supervisor in Oklahoma and Missouri. She has worked with men, women, children, and families on issues including domestic violence, substance use disorders, eating disorders, careers, mental health disorders, trauma, self-esteem, and more. in settings ranging from psychiatric inpatient units to outpatient programs. Amanda Mays, MA, LMFT, is the Director of Recovery Services with Burrell Behavioral Health where she provides clinical supervision in the field of addictions and family dynamics, and coordinates treatment and grant management within her supervised teams.

Chronicles of the 2021 Summer Externs

he Family Health Foundation of Missouri and the American Academy of Family Physician Foundation sponsored six medical students to participate in the MAFP summer externship program. Because of your financial support, we are able to continue this program for medical students interested in family medicine. Here are stories about their experience this summer.

Megan Bastian, MS1

Saint Louis University Externship Site: Mercy Family Medicine Residency This summer I was selected to participate in the MAFP Summer Externship Program at Mercy Family Medicine. The externship was truly an

amazing experience and exactly what I had hoped to gain during my summer break. I requested that during my 4-week externship, I have a varied experience in order to help me better understand the breadth of family medicine and explore what specifically I may be interested in for my own career. I appreciate that Mercy tailored my experience with this request in mind. I was exposed to both outpatient and inpatient care, as well as sports medicine, women’s health, ultrasound techniques, joint injections, in-office procedures, and osteopathic techniques. I additionally attended weekly didactics and grand rounds. It is amazing the breadth of my experience during a short 4 weeks. Throughout my MS1 year, much of my time was taken up by coursework and studying. Without much clinical experience, it was easy to feel burned out towards the end of the year. I wanted a summer experience that would reinforce my love for medicine and patient care, and that is what the MAFP Summer Externship MO-AFP.ORG 17

did for me. It was refreshing to take a break from studying and be able to interact and connect with doctors, residents, and patients. Additionally, it was exciting to be able to make connections between the classroom and real patient care scenarios. It was empowering to observe how what I learned from the year prior is actually used in practice. I am so thankful for the residents and faculty at Mercy Family Medicine who welcomed me, taught me invaluable lessons, and made me feel like part of their team during my time there. I would absolutely recommend this externship to anyone who is interested in learning more about what family medicine has to offer!

Dagny Gould, OMS1

Kansas City University Externship Site: Research Family Medicine Residency After completing my first year of medical school under the constraints of the pandemic, I was yearning for an opportunity to connect to my new community in Kansas City and to explore my interests in Family Medicine. My student externship program with Research Family Medicine Residency at Goppert Trinity Care Clinic exceeded any experience I could have imagined. Before this externship, I had a general idea of what Family Medicine encompasses, but now I better understand the depth and diversity of what practicing Family Medicine entails. I am thankful the program director at Research Family Medicine Residency, Dr. Tieman, tailored my externship schedule to fulfill my request of experiencing a bit of everything. My first week alone lived up to that request. From my first day in clinic, I was reminded of the true scope of the community that can be cared for by Family Medicine physicians by seeing a 5-day old baby, an 87-yearold man, and even two siblings and their mother. I witnessed that holistic preventative care can be fully utilized when there is a sense of community established between the patients and the physicians. The rest of my week introduced me to inpatient medicine, obstetrics, and night shifts. Over the next three weeks, I was able to spend time viewing procedures like C-sections and circumcisions, observing grand rounds while on inpatient medicine, and listening in on lunchtime lectures covering a variety of topics. I also saw how the urban setting provided a wide range of cultures and socioeconomic backgrounds that allowed for the tailoring of care for individual geriatric, pediatric, and even labor and delivery patients. Although I was aware of the range of patients that Family Medicine can treat, I was unaware of the diversity of career paths Family Medicine provides. The path from Family Medicine residency can branch into so many careers. Two of the attendings I had the privilege of working alongside had graduated from the Research Family Medicine residency, but one chose to only work in obstetrics while the other decided to become a full-time hospitalist. During the four total weeks, the importance of the community and patientcentered care was highlighted by the third-year residents. Watching 18

MISSOURI FAMILY PHYSICIAN October - December 2021

the third-year residents graduate halfway through my externship, I saw that even in the span of three years, these residents were able to create such strong bonds with their patients that these patients were willing to drive farther to follow the residents into their new practice. All the residents I was paired with were very encouraging and took the time to help me learn more from the experience. The guidance and mentoring of residents helped me work on my patient interviewing skills, physical exam skills, and developing differential diagnoses while brainstorming possible treatment plans. I am thankful to all the attendings and residents who allowed me to learn from each patient case we saw. Not only did I get to develop my budding skills as a student physician, but I also had the chance to learn about what a residency in Family Medicine could look like. The candid and open conversations residents took the time to have with me helped me to better understand further training and career path options, including the wide number of fellowships available. The importance of community in Family Medicine embodies itself within the Research Family Medicine Residency program, as it has created a strong sense of community between residents and attendings that extended to me even during my brief time there. Overall, I am truly grateful to have this opportunity to work with so many friendly, amazing residents at Research Family Medicine Residency. I learned much about Family Medicine as a specialty and what practicing in an urban community looks like. The student externship program has only increased my appreciation of Family Medicine and my desire to pursue a career in this specialty. As the current chapter vice president of ACOFP at Kansas City University, I will encourage any interested medical students to apply to this program in hopes they can experience what I have been honored to experience.

Stephen Jones, OMS1

Kansas City University Externship Site: UMKC Family Medicine Residency The responsibility of the family physician is extensive and profound - a considerable motivation for why I continue to pursue this particular field in medicine. In my time at Truman Medical Center- Lakewood I was able to immerse myself in several subspecialties that family medicine has to offer, enriching my understanding and respect for the role these healthcare providers occupy. I am walking away from my experience at Truman reinvigorated to continue pursuing knowledge that will be beneficial to the people I look forward to serving in the future. This externship opportunity is fast-paced, and exposes students to the full-spectrum coverage of care offered by family medicine in a hospital setting. The experience is further tailored towards the specific interests of the student. I personally spent a considerable amount of time observing and learning from sports medicine physicians. Many other opportunities exist however, and students

may spend more time devoted to clinic, OB/ GYN, inpatient medicine or OMT if they so choose. As students, we also had the opportunity to attend didactic sessions once to several times per week where we covered topics from prevention-in-medicine, to proper placement/ removal of contraceptive devices. What I wish I had done much sooner in my experience was to take advantage of the friendliness and willingness of nurses, residents and attendings to teach and allow externs to get involved. There is immense power in asking the question, “How may I help”. Many times residents and attendings would allow students to be directly involved in procedures which again may be tailored towards interests and level of comfort from the student. I felt as though I came into this experience unsure of my ability to help real patients with real health questions, but I leave Truman confident in my ability to ask patients the critical questions and to seek out the right resources and specialists to answer those questions I may not know how to answer myself. I would highly recommend an externship opportunity in family medicine to any medical student who is considering this specialty. This experience helped to bridge the seeming contrast between pre-clinical and clinical years, and has definitively given me a renewed sense of purpose and confidence in my ability to think clinically going into year two of medical school. I could not have asked for a better group of people to surround myself with than the medical team at TMC- Lakewood.

Karstan Luchini, OMS2

Kansas City University-Joplin Externship Site: Mercy Family Medicine Residency It was a privilege to be able to spend my summer with the Mercy Family Medicine Residency program. During my first week, I was finishing my preparation for my board exams. After months of studying, I was surprised to see how much board relevant material popped up from exam room to exam room. A certain infection here, a genetic anomaly there, pediatric constipation: it was all in family medicine. I was shocked to see how much of what I had spent the first two years cramming was relevant to the specialty and this got me excited for the rest of the externship. Week two was inpatient family medicine, something I had absolutely zero experience doing before medical school. In fact, the most hospital exposure I had gotten prior to this was a medical school pre-requisite shadowing experience on a pediatric heme/ onc floor. To my surprise, I really enjoyed being on inpatient. The morning rounds, the table discussions, and being there for patients in their worst moments was intriguing and rewarding. It was refreshing to see how the residents on inpatient relied on each-other to come up with solutions for patients and how the attendings were readily accessible and always willing to offer their guidance. It truly was a safe learning environment where everyone from MS3 through the attending level was involved in the patients’

care. I think it is important for students to find programs like this that foster a safe environment for growth and emphasize teambased medicine. Weeks three and four for me were back in the outpatient clinic. Week three was especially interesting. I spent each day with a different attending learning about their special interests and advanced training areas. One day was sports medicine and was loaded with injections and MSK visits, another day was procedure clinic and removing and treating various lesions, the next was dedicated to OMM visits, and another featured didactics where I got to learn alongside the residents. There was so much to learn, and I did my best to be a sponge for that week. In my last week in the program, my attending gave me an opportunity I did not expect. She decided to treat me like a third year and gave me a few patients where I could practice my history and physical and verbal presentations. I was nervous at first, but after spending time with everyone at the program and really assessing the dynamic in the clinic those nerves disappeared. I knew if I needed help, there would be someone would be more than willing to drop what they were doing and give me feedback and guidance. I would advise any student interested in doing the family medicine externship to choose Mercy Family Medicine and go experience St. Louis. There is a diverse patient population and an experienced, well-rounded teaching staff that would be more than willing to put their mark on your career.

Jason Onwenu, OMS1

Kansas City University – Joplin Externship Site: UMKC Family Medicine Residency My externship at the Truman Medical Center – Lakewood/ UMKC residency program was a valuable experience that has transformed my view about family medicine and has added some dimension to the material that I have learned during my first year of medical school. Throughout my time there, I was not only able to gain an understanding of the dynamics of medicine and healthcare but also to participate in patient care with skills both previously and newly acquired. This opportunity has had a dual effect in that it has reinforced my interest in family medicine and that it has made me more excited about rotations and residency. When I first stepped foot into TMC – Lakewood, I already knew that family medicine was an all-encompassing specialty that concerned patients of all ages. I did not know what this truly meant or to what extent this statement held true. During this four-week excursion, I appreciated the broad range of care that family medicine physicians provided to patients, from trigger point injections to IUD insertions to cryotherapy. The armamentarium of a family practitioner seemed inexhaustible. As one resident put it, “When someone on a plane is in need of medical assistance, you better hope that a family medicine doctor is on it; there is only so much that an ENT specialist can do.” The residents that I have encountered made it clear that the eclectic nature of family MO-AFP.ORG 19

medicine kept their minds entertained. The full scope of training and practice—whether it’s inpatient or outpatient, OB/GYN or OMT—and the retention of medical knowledge and proficiency is enticing to me, and I was able to witness this quality in full force during the externship. The most noteworthy attribute of this program was its conducive learning environment which could be explained by the camaraderie and familial relationships between members of the healthcare team. I witnessed the mentorship-like collaboration between the attendings and the residents with the common goal of planning out the best care for the patient. The attendings acted as a source of knowledge and direction and the residents were not afraid to ask for guidance. For instance, a resident told an attending that he had not inserted a copper IUD before, and the attending responded with “You can do this. I’ll be right there to walk you through it.” Residents and attendings alike were more than willing to teach and answer any questions I had to the best of their ability. Furthermore, they always ensured that I was learning by asking me questions and allowing me to participate in certain discussions and procedures. For example, during my first week, I assisted with a trigger point injection and later in the program, I performed my first pap smear under the supervision of an attending and a resident. It is because of these attributes that I can say that I will be ahead of my fellow peers with respect to clinical skills and that this opportunity has been instrumental not only to my interest in family medicine but also to my journey as a physician. To put the icing on the cake, TMC-Lakewood is a safety net hospital, a type of medical facility whose mission is to provide healthcare services to individuals regardless of insurance status. Throughout my externship, I encountered many patients who were underinsured and belonged to at least one marginalized group, whether that be of ethnicity, socioeconomic status, gender/sexuality, etcetera. This opportunity was a godsend in that it dovetailed with my interests of improving healthcare access to these individuals as a future physician. The attendings and residents were more than pleased to discuss with me of the concept of the direct primary care movement and of the Truman Discount, a financial assistance program for patients within the TMC system who do not qualify for Medicaid but cannot afford private health insurance. By the end of the program, I was more eager to learn about ways to remedy healthcare disparities and the healthcare access crisis that runs rampant within our country. Overall, this experience proved to be formative to my role as a student doctor and a future physician and is something upon which I will continuously reminisce as I progress forwardly. During those fleeting four weeks, I was able to acquire new knowledge, practice my clinical skills, and connect with attendings, residents, and other members of the healthcare team. This externship has made such a lasting impact on me that I am considering rotating and/or applying for residency at TMC-Lakewood.

MISSOURI FAMILY PHYSICIAN October - December 2021

Catherine Stout, OMS1

Kansas City University – Joplin Externship Site: Research Family Medicine Residency I was honored to be selected through the American Academy of Family Physicians and the Family Health Foundation of Missouri for the summer externship program at Research Medical Center. I sought this experience to enhance my knowledge to the full scope of Family Medicine in its entirety. Through the help of Dr. Tieman, my supervisor, who also serves as the program director for the Research Family Medicine Residency Program, I was provided a schedule that allowed me to observe both residents and attendings during inpatient services, outpatient clinic, labor and delivery, and OB clinic. I was able to build on my physical exam skills and history taking, in addition to learning entirely new skills sets such as delivery maneuvers and suturing. I could not have asked for a better transitional period from my first to second year of medical school. This enriching experience helped me think like a doctor and hone in on key pieces of a patient’s presentation and history. I felt like part of the team as I engaged in clinical discussions, attended lectures, and was challenged with questions. As I made rounds with residents and saw the integration of everything I had learned over the past year being implemented into clinical practice, I was reminded of why I chose medicine as a career path. It was a privilege to follow alongside so many brilliant and compassionate humans who were either faculty members or residents in training. Each interaction I had with the 20+ physicians I worked with was personalized, insightful and contributed to my desire to pursue Family Medicine. I observed procedures varying from skin tag lancing to neonatal circumcisions. I was also fortunate to have witnessed a surrogate mother deliver a baby as the biological mother witnessed with tear-filled eyes. I am so thankful for Dr. Tieman, her colleagues and staff for making me feel welcome and for adding to my education. Alongside my gratitude for this externship is a gratefulness to my education at Kansas City University. After completing my externship, I have a greater appreciation for KCU’s demanding curriculum as well as a greater understanding of the breadth of career choices Family Medicine can offer. RMC specifically had the unique opportunity to offer more specialized training with tracks available to residents in OB for more focus in maternity care, OMT for more use of handson skills, and even a track in integrative medicine. It was apparent, throughout this clinical experience, that RMC trained exceptional physicians. I recommend this externship to all first-year medical students as it served to be an invaluable and practical application of the basic sciences and fundamental clinical skills I learned within the past year.

MAFP’s Transition to Practice Conference Inspires Students and Residents

s we learn to adapt our lives around COVID-19, the MAFP moved forward with offering the Transition to Practice Conference for Family Medicine Residents and Students in person on August 27-28, 2021 at Capitol Plaza Hotel, Jefferson City. This year’s event attracted over 25 residents and students from St. Louis, Kansas City, Kirksville, Columbia, and Joplin for the two half-day sessions. The gathering was kicked off with a session by Chad Carden who challenged the attendees to be better, both personally and professionally. He helped confirm their decisions to become family physicians! Beth Rosemergey, DO, UMKC Truman Medical Center (UMKC TMC) Program Director noted that if she can connect with a patient, it can turn her day around. These words reflect how a family physician serves his/her patients. Sarah Cole, DO, MAFP past president, shared information about how residents and students can become involved in the academy. And to accommodate the unique needs of residents and students, a breakout session was held for each group: contract negotiations and applying to a family medicine residency, respectively. One student stated that “I am really a family doc after Dr. Cole’s rotations in medical school.” This student was at a crossroads with her specialty because she planned on OB/GYN. Her last statement sums it up, “This is who I am.” Being well is also important.

Attendees were encouraged to “do a reset if your specialty isn’t what you thought it would be.” Beth Rosemergey, DO, highlighted their teaching model that they “train residents to pivot and to go after what they want, so as family medicine changes, they can adapt.” To help offset the stress that we all carry in our daily lives, we took a break and toured the Missouri State Penitentiary tourist attraction, followed by dinner at Prison Brews Microbrewery and Grill. This was an excellent opportunity for networking between attendees from across the state. Saturday morning started with Kathy Pabst, MBA, CAE, MAFP Executive Director, highlighting our leadership opportunities for residents and students. The new alternate resident director and alternate student director were elected (see article on page 23). A detailed session on financial strategies for loan repayment was offered by Joni Adamson with the Missouri Health Professional Placement Services. And Kevin Gray, MD, UMKC TMC reviewed ABFM board certification after residency. Every attendee participated in a procedures workshop on point of care ultrasound co-presented by Jack Wells, MD, University of Missouri Columbia, and Kevin Gray, MD, UMKC TMC. The Missouri Mingle closed the conference with family medicine residency recruiters and other recruiters discussing their opportunities with the residents and students. Looking to the future, we are supporting our residents and students to practice in Missouri and care for our family, friends, and communities.

Thank you to our conference sponsors!

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MISSOURI FAMILY PHYSICIAN October - December 2021

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Wesley Goodrich, DO, MPH, a PGY1 resident at University of Missouri Kansas City Truman Medical Center

Karstan Luchini, OMS-III, Kansas City University, Joplin

New Resident and Student Leadership Elected

wo new leaders were elected by their peers to serve on the MAFP Board of Directors through July, 2022. In August, attendees at the Transition to Practice Conference for Family Medicine Residents and Students elected their representatives on the MAFP Board of Directors. Wesley Goodrich, DO, MPH, a PGY1 resident at University of Missouri Kansas City Truman Medical Center, was elected as the Alternate Resident Director. Dr. Goodrich is passionate about health policy, public health, and family medicine advocacy. His background in performing community health assessments was an invaluable exercise in community surveying and application of concepts in his Master’s in Public Health program. He has experience in a patient-centered medical home for a Missouri Mennonite community. His has served in a variety of leadership positions during medical school at the Burrell College of Osteopathic Medicine. He has also performed research and publications on COMLEX and community assessment data. He received honors and awards for his service including the Gold Humanism Honor Society, Student Doctor of the Year Nominee, and scholarships.

Karstan Luchini, OMS-III, Kansas City University (KCU), Joplin, will represent medical students as the Alternate Student Director on the MAFP Board of Directors. Karstan is also the recipient of the MAFP’s 2021 Summer Externship Scholarship. He has been involved in the Missouri National Guard’s mass vaccination event in Joplin, Springifeld, McDonald County, and Carthage. He has also participated in student research fellowships at KCU which focused on sterilization and sanitizing of 3D-printed personal protective equipment, and whether GATA2 protein replaces GATA1 and XPNA/+ mice to allow them to recover from anemia. He made subsequent presentations on these two fellowship opportunities. He has volunteered in various medical clinics, but most uniquely, he owns farmland and raises boer goats. Our new leaders will serve one year as the alternate director, and matriculate to the director position in their second year of service. We encourage you promote these leadership opportunities to your residents and students for upcoming elections.

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MEMBERS IN THE NEWS

Ramona Mundwiller, MSACOFP’s new Executive Director

MSACOFP Welcomes Ramona Mundwiller

as New Executive Director

an Fawks, DO, FACOFP, Missouri Society of American College of Osteopathic Family Physicians (MSACOF) Board of Governors president announced that Ramona Mundwiller was named as the new Executive Director effective July 1, 2021. Pam Cochran, CMP will be retiring as the Executive Director effective January 31, 2022. During this transition process Ramona and Pam will serve together to advance the goals and mission of the Society. “Ramona’s keen understanding of associations and the osteopathic profession makes her a perfect candidate for the role. She brings with her a wealth of knowledge, skills, and ideas to move the needle on osteopathic family physician practice in Missouri. We are thrilled to welcome her to the MSACOFP.” Fawks said. Mundwiller joins the MSACOFP from the Missouri Community College Association where she spent more than seven years creating events, managing membership, and overseeing grants. Prior to this, she served as marketing and communication coordinator at the Missouri Association of Osteopathic Physicians and Surgeons. “To say I am pleased to join this organization is an understatement. Over the past several years, I have developed my leadership skills to prepare for a position like this. I do have big shoes to fill, however, as Pam Cochran has done an amazing job over the past ten years in this role.” Mundwiller said. “I look forward to working with Missouri’s osteopathic family physicians to continue to bring awareness to their profession.” Ramona is a graduate of Central Methodist University with a degree in Business Administration. She lives in Hermann, Missouri with her husband, Mark. 24

MISSOURI FAMILY PHYSICIAN October - December 2021

Kara Mayes, MD, St. Louis

MAFP Guides Pilot High School Program

n an initiative of the America Needs More Family Doctors Collaborative, the AAFP has partnered with Health Occupations Students of America (HOSA) Future Health Professionals to develop and offer a family medicine competitive event in the organization’s 2021-22 academic year program. Through the partnership, HOSA’s high school and college student members will have the opportunity to gain knowledge about a career path in family medicine through interviews with family physicians, research, and development of a peer-to-peer educational presentation. Kara Mayes, MD, St. Louis, and Kathy Pabst, MAFP Executive Director, participated in the development of this program which aims to engage AAFP active and student members to inspire high school and college students to learn about the dynamic field of family medicine. Through HOSA’s active and engaged network, the program also creates the opportunity to educate high school and college advisors and educators about family medicine.and medical students. Founded in 1988 by the Missouri Academy of Family Physicians as its philanthropic arm, the Family Health Foundation of Missouri (FHFM), is dedicated to improving the health of Missouri families by supporting scientific, educational, and charitable activities through the field of family medicine. The FHFM is a 501 (c)(3) organization and donations are tax-deductible. Donations are accepted at anytime at https://www.mo-afp.org/foundation/fhfmdonation-form/, by mailing a check to FHFM, 722 W. High St., Jefferson City, MO 65101, or by calling the MAFP office.

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review. We love to hear from our members!

CoxHealth Series: A Day in the Life of a Resident

oxHealth, in Springfield, MO, recently used their Facebook platform to share a series of nine posts titled A Day in the Life of a Resident. The posts highlighted Grant Ralston, MD, during his day at Cox South- from before sunrise, reading up on all of his patients and visiting them in their hospital rooms to spending the afternoon seeing clinic patients at Family Medical Care Center. Dr. Ralston is currently a second-year resident at Cox Family Medicine Residency. He is a 2020 graduate of the University of Medicine and Health Sciences - Saint Kitts. He is from Wichita, KS, but family connections familiarized him with Springfield. His grandmother attended today’s Missouri State University, and a cousin worked at CoxHealth. “She always had glowing remarks about the health system, and Steve Edwards,” he says. Such elements laid the groundwork for his decision to interview with the program – and, after interviewing at a lot of places, that made the difference in his decision for Cox. He spoke of the kindness and genuine spirit of those connected with the program. “I could tell it wasn’t fake,” he says. “Once I interviewed, I knew this was where I needed to be.” When Dr. Ralston finishes in 2023, he will become one of more than two hundred physicians who have completed the Cox FMR program. A former track athlete, even competing on the collegiate level, he hopes to pursue a Sports Medicine fellowship. Cox FMR draws physicians from all across the country and gives them the opportunity to train in full scope medicine as they serve patients in both clinic and hospital settings. You can read more about the program, faculty, and residents at www.coxfmr.com.

Dr. Grant Ralston is currently a second-year resident at Cox Family Medicine Residency.

Karissa Merritt, DO, Selected as Larry A. Green Visiting Scholar

K Karissa Merritt, DO, Cox FMR Class of 2021

arissa Merritt, DO (Cox FMR Class of 2021) was selected as a Larry A. Green Visiting Scholar through the Robert Graham Center. The center hosts a one month visiting scholars program focused on health policy analysis relevant to primary care and family medicine, with the goal of producing a manuscript related to the month’s research. Dr. Merritt, along with Yalda Jabbarpour, MD; Stephen Petterson, PhD; and John Westfall, MD, MPH, wrote an article entitled State-Level Variation in Primary Care Physician Density that was published in the August 1, 2021 issue of American Family Physician. (https://www.aafp.org/afp/2021/0800/p133.html) MO-AFP.ORG 25

References

Buprenorphine — pages 12-14

11. Carroll, Gerard G et al. “Buprenorphine Field Initiation of ReScue Treatment by Emergency 1. “Understanding the Epidemic.” Centers for Disease Medical Services (Bupe FIRST EMS): A Case Control and Prevention, Centers for Disease Control Series.” Prehospital emergency care : official journal and Prevention, 17 Mar. 2021, www.cdc.gov/ of the National Association of EMS Physicians and opioids/basics/epidemic.html. the National Association of State EMS Directors vol. 2. “About CDC’s Opioid Prescribing Guideline.” 25,2 (2021): 289-293. doi:10.1080/10903127.2020 Centers for Disease Control and Prevention, Centers .1747579 for Disease Control and Prevention, 17 Feb. 2021, www.cdc.gov/opioids/providers/prescribing/ 12. United States, Congress, Office of the Secretary, and Neeraj Gandotra. Practice Guidelines for the guideline.html. Administration of Buprenorphine for Treating Opioid 3. “Become a Buprenorphine Waivered Practitioner.” Use Disorder, 28 Apr. 2021. www.federalregister. SAMHSA, Substance Abuse and Mental Health gov/documents/2021/04/28/2021-08961/ Services Administration, 14 May 2021, www. practice-guidelines-for-the-administration-ofsamhsa.gov/medication-assisted-treatment/ buprenorphine-for-treating-opioid-use-disorder. become-buprenorphine-waivered-practitioner. Accessed 11 July 2021. 4. Srivastava, Anita et al. “Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone?.” Canadian family physician Medecin de famille canadien vol. 63,3 (2017): 200-205. Family Medicine 5. Coe, Marion A., et al. “Buprenorphine Pharmacology Opportunities in Review: Update on Transmucosal and Long-Acting Metro, Mid-size & Formulations.” Journal of Addiction Medicine, Rural Locations vol. 13, no. 2, 2019, pp. 93–103., doi:10.1097/ adm.0000000000000457. Mercy Clinic is seeking Family Medicine Physicians 6. Substance Abuse and Mental Health Services to join our established practices in St. Louis, Joplin, Administration. Buprenorphine Quick Start Springfield, and more! Guide, Substance Abuse and Mental Health Mercy’s Family Medicine Positions Offer: Services Administration, 2021, www.samhsa. • Variety of practice options to choose from including gov/medication-assisted-treatment/medicationsoutpatient, traditional, emergency medicine or hospitalist counseling-related-conditions/buprenorphine. • Residency Stipend for early commitment 7. Shulman, Matisyahu, et al. “Buprenorphine • Commencement Bonus Treatment for Opioid Use Disorder: An Overview.” • Competitive compensation model • Generous and comprehensive benefits package CNS Drugs, vol. 33, no. 6, 2019, pp. 567–580., • 200-year history; let us share this incredible story with you! doi:10.1007/s40263-019-00637-z. • Physician Wellness Program 8. Wightman, Rachel S., et al. “Opioid Overdose Deaths • Relocation assistance • Professional liability coverage with Buprenorphine Detected in Postmortem • Faith-based, not for profit with a focus on an exceptional Toxicology: a Retrospective Analysis.” Journal of patient experience Medical Toxicology, vol. 17, no. 1, 2020, pp. 10–15., Mercy Family Medicine groups are a part of Mercy Clinic, a physiciandoi:10.1007/s13181-020-00795-3. led and professionally managed multi-specialty group. With over 9. Chen, Kelly Yan, et al. “Buprenorphine–Naloxone 2,500 primary care and specialty physicians, Mercy Clinic is ranked Therapy in Pain Management.” Anesthesiology, one of the largest integrated physician organizations in the country. vol. 120, no. 5, 2014, pp. 1262–1274., doi:10.1097/ For more info, contact: Lisa Hauck - Physician Recruiter (East) aln.0000000000000170. Office: 314-364-2949 | Fax: 314-364-2597 | Email: Lisa.Hauck@mercy.net 10. Velander, Jennifer R. “Suboxone: Rationale, Science, For available openings visit careers.mercy.net Misconceptions.” The Ochsner journal vol. 18,1 (2018): 23-29. 26

MISSOURI FAMILY PHYSICIAN October - December 2021

Family Medicine Residents (2021-2022)

Megan Aspelund, DO

Sadia Bashir, DO

Jason Buchan, DO

Nicholas Comstock, DO

Stephanie Gonzales, DO

Katherine Holbrook, DO

Jennifer MacSwords, DO

Quinn Quebodeaux, DO

Gabriel Skiba, DO

Patrick Terry, DO

Molly Thompson, DO

Hau Tran, DO

Sydney Priest Wood, DO

Dominick Wright, DO

MO-AFP.ORG 27

2021-2022

COX FAMILY MEDICINE RESIDENCY Third-Year Resident Physicians

Jacob Bolt, MD

Rachel Brown, DO Chief Resident

Margaret Givens, MD

Edward Hansen, DO Chief Resident

Shelby Laughlin, MD

Mario Martinez, MD, PhD

Kristen Snyder-Hernandez, MD

Rachel Watson, DO

Victoria Jackson, DO

Second-Year Resident Physicians

Brittany Dahlager, DO

Joshua Etcheson, DO

Alexandra Jones, DO

Hannah McCarthy, MD

Sara Neibauer, DO

Nichole Norgard, DO

Grant Ralston, MD

Duncan Tillack, DO

Jordan Moore, MD

First-Year Resident Physicians

Jackson Bagby, DO

Alexandra Cooke, DO

Christopher Flud, MD

Rebecca Fryer Gordon, DO

Alex Hagaman, DO

Kayla Hufham, MD

Trey Hufham, MD

Blessy Joseph, DO

Jennifer Kaberline, MD

Taylor Wehmeyer, DO

MISSOURI FAMILY PHYSICIAN October - December 2021

FAMILY MEDICINE RESIDENTS 2021-2022

Kayla Beashore, DO PGY 1

Neil Bobenhouse, DO PGY 1

Max Hesse, MD PGY 1

Jason Woody, DO PGY 1

Dina Helina, DO PGY 2

Nicholas Faron, DO PGY 2

Kayla Thomason, DO PGY 2

Shawn Khosla, DO PGY 2

Tyler Marler, DO PGY 3

Ashlyn Patterson, DO PGY 3

Andrew Perry, DO PGY 3

Kimberly Schwartzkopf, DO PGY 3

Monica Unterreiner, DO PGY 3

Jacob Yankowitz, DO PGY 3 MO-AFP.ORG 29

Mercy Family Medicine 2020-2021 Resident Roster

First-Year Resident Physicians | Class of 2023

Elizabeth Hoover, DO Advisor: PHRUTTITUM

Viola Hoxha, MD

Advisor: HOEKZEMA

Megan Landis, DO Advisor: VERNA

Catherine Baker, MD Advisor: WHITE

Michele Sun, MD Advisor: WILFLING

Raphael Yang, MD Advisor: DANIS

Second-Year Resident Physicians | Class of 2022

Chelsea Daniels, DO

Emily Govro, DO

Corinne Halsted, DO

Ha Hatley, MD

Adam Reinagel, MD

Shivi Yadava, DO

Advisor: PHRUTTITUM

Advisor: DANIS

Advisor: WHITE

Advisor: HOEKZEMA

Advisor: VERRY

Advisor: WILFLING

Third-Year Resident Physicians | Class of 2021

Chelsea Drissell, MD

Vanessa Murillo, MD

Kris Pullam, MD

Larry Rudolf, MD

Advisor: WHITE

Advisor: PHRUTTITUM

Advisor: WILFLING

Advisor: DANIS

Your life is our life’s work. 30

MISSOURI FAMILY PHYSICIAN October - December 2021

STL_37046 (7/16/20)

Amanda Schumacher, DO Advisor: HOEKZEMA

Kevin Sidhu, DO Advisor: VERRY

MO-AFP.ORG 31

Tarek Haidar, MD

Tina Fleres, MD

Julian Carrier, DO

Samer Abu-Amer, MD

Cristianna Abilez, MD

John Brewer, DO

Casey Tramp, MD

Terry Suppes, DO

Faculty

Kavitha Arabindoo, MD, MPH

Jennifer Tieman, MD Program Director

Luke Lambert, DO

Abbie Heaton, DO,MA

Patrick Akin, DO

Julie Wood-Warner, PhD

Revathi Bhat, MD

Matthew Landeen, DO

Wes Hoskyns, DO

Stephanie Baker, DO

Ashley Cefalu, DO

Oct-21

Henry Lau, DO

Gretchen Beer, DO

Duff,

Bridget Leinenbach, DO

Valerie

Samuel Maples, MD

Elizabeth Montgomery, DO

Alex Ondracek, DO

Class of 2024

Savanna Lee, DO

Class of 2023

Arian Culp, MD

Katherine Field, DO

Tricia Fairchild, MD

Class of 2022

Cristina Enrique, DO

Oct-21

Faculty

Emily Rogers, DO

Taylor Patterson, DO

Alexander Gabrovsky, MD

Nicholas Comninellis, MD, MPH

Brent Hrabik, MD

Gazala Parvin, MD

Jordan Snook, DO

Ali Sayed, MD

James Sweeney, DO

Stephanie Schauner, PharmD

Anne Sly, MD

Austin Traasdahl, DO

Kaylee Shrauger, MD

Conrad Bajor, DO

Emily Vahrenberg, MD

Brian Taylor, MD

Long Bui, DO

Dani Wermuth, MD

Asher Wagnon, MD

Sabina Lin, DO

2021-2022 R3 CHIEF RESIDENTS

Tatum Mead, PharmD

Adjunct Faculty

INMED Institute for International Medicine Founder & CEO

Jennifer Kelley, MD

RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM, KANSAS CITY

Saint Louis University

Family Medicine Residency 2021-2022

Jacquelyn Bailey, MD, MPH PGY3 – Chief Resident

Alexandra Sawicki, DO PGY3 -- Chief Resident

Marco Garcia, DO–PGY3

Jacob Lanter, MD–PGY3

Antonio Rosales, DO–PGY3

Hannah Webber, MD–PGY3

Ryan Allen, MD–PGY2

Jessica Auld, MD–PGY2

Anthony Hang, DO–PGY2

K. Alston Lee, DO–PGY2

Dymon Morgan, MD–PGY2

Carmen Purvis, MD–PGY2

Meghan Hernandez, DO–PGY1

Sravya Motheramgari, DO–PGY1

Victoria Phillips, MD–PGY1

Kemdi Egekeze, MD, MPH–PGY1 Chyleigh Harmon, MD–PGY1

SSM Health St. Mary’s Hospital Family Medicine Inpatient Service

Kerri Raleigh, MD–PGY1

MISSOURI FAMILY PHYSICIAN October - December 2021

DEPARTMENT OF FAMILY & COMMUNITY MEDICINE UNIVERSITY OF MISSOURI | SCHOOL OF MEDICINE 2021-2022 HOUSE STAFF Chief Residents

Cynthia “Brea” Lombardo, MD SP-Blue

Diane Bussan, MD SP-Blue

Ryan Muehling, MD Fayette

Marc Propst, MD Fulton

Third-Year Residents

Zachary Barker, DO Fulton

Brook “Beau” Bounous, DO Fayette

Reiana Mahan, MD SP-Blue

Oyenmwen Edo-Ohonba, MD Compass

Humza Quadri, MD SP-Blue

Eva “Veronika” Kiss, MD Compass

Jason Fultz, DO SP-Blue

McKenzie Veldhuizen, MD Fayette

Jacob Seevers, DO Fulton

Stephanie Zaﬁris, MD Fulton

Second-Year Residents

Sarah Bohnert, MD Fulton

Seth Mobley, DO SP-Blue

Maggie Brennan, MD Compass

Hannah Braungardt, DO Fayette

Colbert Nelson, DO SP-Blue

Melanie Oler, DO SP-Blue

Danielle Poivre, MD Compass

Brooke Dean, MD Fulton

Daniel Lyon, DO SP-Blue

Dalton Lohsandt, MD Fayette

Conner Sutton, MD Fulton

Christine White, DO Fulton

Adam Larey, MD SP-Blue

Grayson Mynatt, DO SP-Blue

Eliza Owens, MD Fulton

Roma Sobieski, MD Fayette

Claire Wolber, MD Fulton

Lance Workman, MD Fulton

Nicole Seddon, MD SP-Blue

Andrew Wright, DO Fayette

First-Year Residents

Tori Applegren, MD SP-Blue

John Bocinsky, MD SP-Blue

Jennifer Cheung, DO SP-Blue

Bilal Quadri, MD SP-Blue

Jane Salutz, MD Fulton

Nicole Formhals, MD Compass

Allyson Sanders, MD SP-Blue

Ryan Peach, DO Fayette

Integrated Residents

Paige Beauparlant

Brent Dudenhoeffer

Cheyenne Dudenhoeffer

Samuel Holt McNair

Elise Sherman

MO-AFP.ORG 33

MISSOURI FAMILY PHYSICIAN October - December 2021 Morgan Murray, MD UMKC

Chris Moyer, DO Des Moines University

Bailey Martin, MD University of MO-Columbia

Caroline Ward, DO Kansas City University

Stacey Leber, DO Des Moines University

Marshall Taylor, DO Oklahoma St University

Tess Meklir, MD Alaska Fam Med Maternity Care Fellow

Burrell College of Osteopathic Medicine

Wesley Goodrich, DO, MPH

Joshua Go, DO Kansas City University

Kathryn Estes, DO Des Moines University

Bailey Englund, DO Kansas City University

Rebecca Aguayo, MD University of MO-Columbia

Kristin Adams, MD University of Oklahoma

Seenu Abraham, MD UMKC

Annie Abbott, DO Kansas City University

Eddy Ndichie, MD Rutgers University SOM

Matthew Myrick, MD

Maranda Nguyen, DO UMKC Fam Med Maternity Care Fellow

American University Of the Caribbean

Desztini Howard, MD Meharry Medical College

Miki Andrus--Bearden, DO Kansas City University

Logan Hemme, MD UMKC

Tasfia Ahmed, DO Kansas City University

John “Tony” Phillips, MD UMKC

Haley Kertz, MD UMKC

Crystal Brown-Vredenburg, MD University of KS-Wichita

Tricia Nguyen, MD, MBA Salwa Abdelwahed, MD, MBBCh University of TN Internal Med Assiut University Geriatric Medicine Fellow Faculty of Medicine Geriatric Medicine Fellow

Monica Paulson, DO Kansas City University

Taylor Keen, DO ATSU Kirksville

Sonia Hussain, MD SABA University

Hannah Pancoast, MD University of MO-Columbia

Cicilia Ariga, MD University of Kansas

Annette Anwander, MD University of Kansas

Zahn Raubenheimer, MD Trinity College Dublin SOM

Matthew LeBaron, DO Franciscan Health Fam Med Sports Medicine Fellow

Texas College of Osteopathic Medicine

Gregory Smith, DO

Sunita Kolareth, MD UMKC

Hai Song Kim, DO

Turro College of Osteopathic Medicine—Middleton

Joshua Chan, DO Kansas City University William Burkhart, MD East Tennessee St

Theo Zemanuel, DO Cox Fam Med Sports Medicine Fellow

Jarom Spencer, DO Des Moines University

Taylor Lacy, MD UMKC

Mallory Dameron, DO ATSU Kirksville

ADVOCACY DAY FEB. 28 - MARCH 1, 2022

JOIN US AT CAPITOL PLAZA HOTEL & THE MISSOURI STATE CAPITOL, JEFFERSON CITY, MO

MONDAY, FEBRUARY 28 6:30 pm – 8:30 pm Legislative Briefing of Key Issues and Dinner, Capitol Plaza Hotel TUESDAY, MARCH 1 8:00 am – 1:00 pm Legislative Briefing and Breakfast, Capitol Plaza Hotel Visit Legislators’ Offices (Appointments to be scheduled for you by MAFP staff) (Lunch at hotel) 1:30 – 4:00 pm Board of Directors Meeting

We will be offering a live stream of Monday evening’s detailed legislative briefing through Zoom, but you will still need to register so we can plan accordingly. AND…we will have an opportunity for you to contact your legislators through a Speak Out portal. We will craft a message for you to use, or create your own.

CALLING ALL MEDICAL SCHOOLS & RESIDENCY PROGRAMS

Send a group of students or residents to attend this important legislative meeting. Let’s show our legislators that we are united and serious about taking care of our patients and protecting the scope of practice for family physicians. *A limited number of complimentary sleeping rooms are available through MAFP. Contact Kathy Pabst at kpabst@mo-afp.org or 573.635.0830 for more information.

YOU ARE THE VOICE OF MISSOURI FAMILY PHYSICIANS! MO-AFP.ORG 35

Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101

ADDICTION HELP AND RESOURCES MO Department of Mental Health – Behavioral Health Resources 800-575-7480 Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline 1 (800) 662-HELP (4357) 1 (800) 487-4889 (TDD) for hearing impaired Confidential information service for individuals and family members faced with substance use disorders and/or mental health issues. Information available in English and Spanish. National Council on Alcoholism and Drug Dependence, Inc. (NCADD) 1 (800) NCA-CALL (622-2255) NCADD’s HOPE LINE directs callers to numerous affiliate programs around the country to assist, at a local level, with substance use issues. National Suicide Prevention Lifeline 1 (800) 273-TALK (8255) Not just a suicide hotline, this lifeline offers help with issues of drug and alcohol use.