Arizona Physician Magazine, April 2017 by Maricopa County Medical Society (MCMS)

A combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society

April 2017

Facing down a crisis: physician thoughts on opioids pg. 10

Conquering pain: a team approach with

Patrick Hogan, DO pg. 23

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ARIZONA PHYSICIAN | April 2017

VOLUME 1, ISSUE 4 EDITOR-IN-CHIEF JAY CONYERS, PhD

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Contents

MANAGING EDITOR SHARLA HOOPER

Physician Profile

shooper@arizonaphysician.com

Prescribing caution & implementing a team mentality to treatment alternatives makes pain management simpler, safer, and more effective. With Patrick Hogan, DO.

ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS dperkins@arizonaphysician.com

PHOTOGRAPHY DENNY COLLINS

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LAYOUT & PRINTING PRISMA

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EDITORIAL BOARD GRETCHEN ALEXANDER, MD MICHAEL BUGOLA, MD JOHN COUVARAS, MD MICHAEL DEAN, MD TIMOTHY FAGAN, MD TABITHA MOE, MD ROBERT ORFORD, MD WILLIAM THOMPSON, MD JAREN TROST, MD

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23 Features 10 14

Turning the Tide on Opioid Misuse and Abuse Promoting Responsible Prescribing & Dispensing Policies & Practices

30 39

Opioid Prescribing & Regulation: What Physicians Think Combatting the Opioid Epidemic

In This Issue 8 President’s Page

28 Event Photos: Public Health Forum

17 Perspective: Pain as 5th Vital Sign

36 Legal: Defending Public Access

19 Perspective: Better Pain Management

42 Community: Sonoran Prevention Works

6 What’s Inside

34 Legal: Liability and Compliance

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To the Editor Dear Editor, Congratulations to you and your staff on the outstanding inaugural issue of Arizona Physician. This new publication will have important information for all physicians in our state – regardless of her/his specialty. For a physician new to Maricopa County, I find this issue to be extremely helpful, from learning about my “go-to” legislators to finding out about important programs available to those in need of comprehensive and rational health care. Your new magazine will lead the way, for me as well as for tried and true Arizona physicians. Excellent work! Stephen P. Herman, MD, LFAPA, DFAACAP

We encourage our readers to submit Letters to the Editor and share your opinions, observations and insights on the content and topics we offer in our monthly magazine. Please submit your Letter to the Editor via email at (information@ arizonaphysician.com), or the old-fashioned way at (326 E Coronado Rd, Phoenix, AZ 85004). Please follow us on Twitter and Facebook as well!

HCAHPS: Important Reporting Change effective October 2017 The CY 2017 OPPS Final Rule has been published and is now available on the Federal Register. The Final Rule is available at the following URL: https://federalregister.gov/d/2016-26515. CMS is finalizing the removal of the Pain Management dimension from the scoring formula used in the Hospital Value-Based Purchasing Program (Hospital VBP), beginning with the FY 2018 payment adjustments. The Pain Management dimension is derived from Questions 12, 13 and 14 on the HCAHPS Survey. Please note that the Pain Management questions will remain on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey and the Pain Management measure will continue to be publicly reported on Hospital Compare. Please monitor the HCAHPS Web site for future announcements about the Pain Management measure, http:// www.hcahpsonline.org/whatsnew.aspx.

April 2017 | arizonaphysician.com

What’s Inside APRIL 2017

Jay Conyers, PhD

You’ve got the biology of dependence or addiction to opioids driving it. You also have financial incentives for people to stay sick through Social Security disability insurance compensation. You’ve got doctors who are incredibly incentivized in many ways to continue to prescribe. I really feel like the opioid epidemic is the canary in the coal mine with regards to our healthcare system. We have some serious infrastructure issues that we need to reform.” Anna Lembke, MD

few months back I was out for a run (well, a slow jog, or slog, as I like to call it) and I was listening to an interesting podcast from Stanford Medicine, which posts wonderful interviews with local healthcare experts. The audio fuel for my slog that day was with Stanford psychiatrist and addiction researcher Dr. Anna Lembke. She was promoting her recent book, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, which shares her 20+ years of experience helping people with addiction. In the podcast, she provides a poignant narrative on the root cause of the problem. Her comment on the complexity of the opioid crisis caught my attention and made me think long and hard about what truly contributes to the addiction spiral. As we all know, it’s not a simple answer. Doctors are taking a lot of the heat for the problem, and rightfully so. A recent study published in the New England Journal of Medicine (N Engl J Med 2017; 376:663673) examined the prescribing patterns in emergency departments (ED). Reviewing records for more than 215,000 Medicare patients, the study compared the prescribing frequency of treating physicians. Those who were considered high prescribers – that is, those in the top quarter of prescribing rates – doled out opioids to 1 in 4 patients. In contrast, prescribers in the lowest quartile only recommended opioids for pain 7% of the time. The study followed the patients who received an ED opioid prescription and found that those who saw a high prescriber had a 30% greater chance of developing an addiction. Specifically, the study authors looked at whether patients were still refilling their prescriptions months from the time of treatment. 6

ARIZONA PHYSICIAN | April 2017

Despite this study focusing on ED physicians, many suggest the problem extends to physicians in internal medicine and primary care. It’s not a specialty problem, for certain. Fortunately, there are numerous approaches to better educate opioid prescribers. But while many states have implemented Prescription Drug Monitoring Programs, one size doesn’t fit all. Programs differ greatly, and some even have built-in mandates requiring physicians to log prescriptions on a closely-watched pharmacy database. Here in Arizona, ours is still in its infancy, but many proposed changes are on the horizon. Aside from this, what else is being used to address the overprescribing problem? One idea is an alternative approach referred to as academic detailing, which I read about in a recent report by Davis et. al. (Pain Physician, 2017 Feb;20(2S):S147-S151). Their study examined the effectiveness of educational outreach in a one-on-one format, similar to how the pharmaceutical industry deployed ‘detailers’ to physician offices to provide evidence-based information about the efficacy of their medications. This approach is widely accepted by the physician community, with myriad examples to support the results. While not yet proven to be effective for opioid prescribing, the authors are optimistic it will parallel the successes of similar approaches for other conditions such as COPD and atrial fibrillation. But what about physicians using opioids themselves? I was surprised to read that while addiction rates for U.S. citizens range from 8-10%, it’s as high as 15% for the physician community. One would think that a professional community well aware of the dangers of opioids would

An allopathic physician’s and physician assistant’s participation in PHP may [emphasis added] be confidential if there are no related criminal charges, patient care issues, or statutory violations. Of all the calls I receive each month from member physicians, or others just looking for a resource, the most common, without question, concerns addiction. Many ask about reporting requirements for colleagues they suspect are abusing alcohol or prescription drugs. In many of the calls, I can hear the concern, the fear, the uncertainty. They worry about the repercussions of self-reporting, or enrolling voluntarily in treatment programs. Curious about our state-run program, I consulted Dr. Michael Sucher, who oversees the program for the AMB. As an addiction medicine specialist, Dr. Sucher is committed

to helping physicians who battle substance abuse. I was elated to hear that our program touts an 85-90% success rate, and stands by its commitment to confidentiality. While the treatment files are technically owned by the AMB, Dr. Sucher ensures that the records are subpoena-proof, and not reviewable by medical board staff. Voluntary enrollment in the program does not trigger reporting to the Federation of State Medical Boards (FSMB), or the National Practitioner Data Bank (NPDB). Truth be told, it’s a program committed to maintaining a low profile, and ensuring confidentiality. Resources are available for patients and physicians alike, but they’re not always easy to find. We encourage Arizona physicians to read up on the opioid crisis, the programs accessible to our communities, and the risks associated with overprescribing. It’s evolved into an epidemic, and one would be hard-pressed to argue otherwise. But help is available, for your patients, and for you. So what about this issue of Arizona Physician? We start by profiling a physician who truly operates on the front lines of the opioid epidemic. Patrick Hogan, DO, serves as CEO of both Arizona Pain Doctors, and the Arizona Society of Interventional Pain Physicians, and shares his thoughts on the crisis. We also feature updates from the Arizona Department of Health Services (ADHS) leadership on our state’s work to address both prevention and treatment of opioid addiction, as well as our survey results on opioid prescribing. We look at Continuing Medical Education around opioids, and highlight a student essay on the topic, penned by A.T. Still University medical student Mary Ann Davies. We profile Sonoran Prevention Works for our community health partner corner, and include a wonderful article from Dr. Uzma Jafri looking at pain as the fifth vital sign. Lastly, MICA shares with us an assessment of the compliance and liability risks in pain management. It’s a packed issue, as usual! Next month, we focus on physician payment, and we ask the hard questions: Do you get your fair share? Do you constantly battle to get reimbursed? Are there too many stopgaps in place to slow down payment? We look at all of these issues, and then some. We’ll profile Dr. Michael Mills, gastroenterologist at Arizona Digestive Health, and ask him about the problems physicians face in today’s payment landscape. We have another packed issue in store, so we hope you enjoy it! Jay Conyers, PhD, is the Editor-in-Chief for Arizona Physician and serves as Executive Director of the Maricopa County Medical Society.

Comments on Opiods

be less likely to abuse them. However, given the levels of anxiety, stress, and burnout inherent in the profession, physicians are as susceptible to addiction as they are to any other disease. Take for example the case of Dr. Peter Grinspoon. A few years back, Dr. Grinspoon was a highly-successful primary care physician, practicing in Boston, and teaching at Harvard Medical School. It took a visit from the DEA and local law enforcement authorities before he was able to face his addiction head-on. His medical license was revoked and his marriage ended. He didn’t practice for more than four years. In his words, he hit rock bottom. Fortunately, he was saved by the Massachusetts Physician Health Service, a program not too unlike our own program here in Arizona. He endured the rigorous five-year program, and came out a changed man. Once he regained his medical license, the very program that oversaw his rehabilitation asked him to join their staff. In his new role as Associate Director of the program, he now helps other physicians fighting addiction. Dr. Grinspoon chronicled his journey in his book, Free Refills: A Doctor Confronts His Addiction. He now advocates for reforming abuse treatment programs and their relationship with medical regulatory bodies, advocating for more emphasis on compassion and treatment, and less on punishment, sanctions, and license revocation. Why? For one, he points to the success rates of physicians who willingly enroll in such programs. Up to 80% of physicians seeking treatment successfully complete treatment programs. That’s a much higher clip than the general population. The stigma of addiction or alcohol abuse, and the fear that medical boards will revoke their licenses, lead many to ignore the problem and keep it hidden. Many worry that even if they enroll in a physician substance abuse program voluntarily, board punishment might still be a reality. What about here in Arizona? Sponsored by the Arizona Medical Board (AMB), the Physician Health Program (PHP) is run by an outside entity, which contracts with the AMB to oversee the program. The program serves licensed allopathic physicians and PAs, and is authorized pursuant to state law (A.R.S. 32-1452). While the program offers confidentiality under specific circumstances, many physicians have reservations. The official website for the AMB states:

Look for quotes from our survey respondents throughout this April issue of Arizona Physician Magazine.

April 2017 | arizonaphysician.com

President’s Page EFFECTIVE OPIOID POLICY MUST BE COMPREHENSIVE

rom time to time, I encounter colleagues who question whether a true opioid crisis exists. “This seems like a bit of an overreaction,” they comment. “Patients in my practice don’t have issues with opioid pain medications.” Statistics, however, tell a different story. According to the CDC, prescription drug overdose deaths in the U.S. tripled between 1999 and 2014, with over 60% involving prescription opioids. Mortality rates continued to rise in 2015 with a total of over 33,000 opioid-related deaths in the U.S.1. In Arizona, 494 deaths across the state in 2014 were attributed to prescription opioids, 180 deaths to heroin overdose, and annual healthcare costs related to opioid misuse in Arizona have been estimated at $689 million2. These human and economic losses occur not only in the context of opioid addiction – in 2015, two million American adults met criteria for opioid use disorder – but of other conditions, including chronic pain. The National Institutes of Health (NIH) has estimated that over 100 million Americans suffer from chronic pain, which in recent decades has increasingly been treated through the prescription of opioid pain medications rather than alternative modalities3. Reasons for increases in the prevalence of chronic pain are unclear, and may include a diverse array of factors including psychosocial determinants. Recent work, for example, suggests that economic insecurity contributes to increased perceptions of pain4, and may be one driver for what some have termed an epidemic of chronic pain which parallels the opioid epidemic. Complicating factors in the treatment of chronic pain include depression and anxiety, which are known to be risk factors for both pain and for addiction, and to predict poorer outcomes for pain treatment. A known biological substrate for this association exists: data from functional MRI studies demonstrates that areas of the brain such as the anterior cingulate cortex and the amygdala which are known to be associated with depression and anxiety, are activated during the perception of pain. Against this complicated backdrop, Arizona leaders are working to create policies which will reduce harms associated with both prescription and illicit opioids. In the last year, progress has been made in the area of prevention: statutes 8

ARIZONA PHYSICIAN | April 2017

Gretchen Alexander, MD Arizona Medical Association

and executive orders have mandated more consistent checks of the Controlled Substance Prescription Monitoring Program (CSPMP) database, limits on supplies of opioid pain medications that can be prescribed at once, and education for prescribers. These interventions are important, and may reduce opioid-related harms down the road, as regulation and education of prescribers works to reduce both the amount of opioid pain medication accessible in the community, and the number of patients who are placed at risk for opioid addiction through introduction to pain medications. In building on this promising start, it is important to ensure that Arizona develops policy solutions which are both comprehensive and thoughtful. The opioid crisis itself is the unintended consequence of ill-considered policy decisions that were made in the 1990s, and culminated in many state medical boards creating guidelines which imposed disciplinary action on physicians who failed to adequately treat their patients’ pain. Good opioid policy must include comprehensive treatment measures as well as prevention. Recent evidence suggests that prevention efforts on their own may not decrease opioid overprescription and overdoses, at least in the short term. In a study published in the New England Journal of Medicine in 2016, Meara et al evaluated the association between the imposition of state-level opioid prescribing restrictions and four measures of opioid misuse including non-fatal opioid overdoses among disabled Medicare recipients, and found no significant improvement in any of the four measures5. The current population of patients who are already in trouble with opioids must not be ignored, if we are serious about preventing opioid-related deaths in Arizona. The most effective policy provides for comprehensive solutions which incorporate prevention as well as treatment for current addicts. Treatment strategies including medically assisted treatment (MAT) with opioid agonists such as buprenorphine and methadone, both of which have well-established track records of success in the treatment of opioid use disorder, should be supported and access to these treatments expanded. Preliminary evidence also suggests that opioid antagonist treatment with naltrexone can be effective as well, under certain circumstances. However, sustained sobriety may be obtainable

only with long-term (greater than 12 months) therapy; adherence rates are lower than for opioid agonist therapy and there is evidence that overdose deaths rates are increased among patients who are being treated with naltrexone and then relapse6. Additionally, most studies suggest that medically assisted treatment is successful primarily when counseling is provided at the same time as medication. Access to intensive counseling programs must be supported and expanded in order to ensure that medication treatments for opioid use disorder are effective. Currently, commercial insurers vary widely in their coverage of such services and cumbersome prior authorization requirements constitute a barrier to timely medical care for patients seeking treatment. Excellent recommendations offered to the Arizona Substance Abuse Task Force Access to Treatment Work Group in 2016 included the following: • Expansion of funding for inpatient programs for substance use treatment

are typically complex, with clinically challenging presentations involving chronic pain, depression, anxiety, substance use disorders and chronic psychosocial and economic stress. Effective interventions for them must involve well-integrated treatment approaches and decent access to care. Such measures are not inexpensive, but given that the healthcare costs of opioid overuse and misuse in Arizona have been estimated to be close to $700 million per year, funding such approaches would appear to be a wise investment for our state. References 1

Rose A. Rudd; Puja Seth; Felicita David; Lawrence Scholl. Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010–2015 Morbidity and Mortality Weekly Report. December 30, 2016 / 65(50-51);1445–1452

http://www.drugfree.org/wp-content/uploads/2015/04/ Matrix_OpioidAbuse_040415.pdf

https://prevention.nih.gov/docs/programs/p2p/ ODPPainPanelStatementFinal_10-02-14.pdf

Eileen Y. Chou, Bidhan L. Parmar Adam D. Galinsky. Economic Insecurity Increases Physical Pain. Psychological Science 2016, Vol. 27(4) 443–454

Ellen Meara, Jill R. Horwitz, et. al. State Legal Restrictions and Prescription-Opioid Use among Disabled Adults. N Engl J Med 2016; 375:44-53

Marc A. Schuckit. Treatment of Opioid-Use Disorders. N Engl J Med 2016; 375:357-368

http://substanceabuse.az.gov/sites/default/files/meeting-documents/Substance%20Abuse/minutes/sfh_edits_09-12-16_draft. docx_rev_0.pdf

• Expansion of intensive outpatient treatment programs • Expansion of options for detoxification treatment • Re-establish the CPS Substance Abuse Treatment Fund, required by statute but not funded since 20097 These recommendations should be given consideration as part of a comprehensive, integrated opioid policy for Arizona. Patients with dependence on prescription and non-prescription opioids and who are at the greatest risk for death from overdose

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Turning the Tide on Opioid Misuse and Abuse 10

ARIZONA PHYSICIAN | April 2017

B Y C A R A C H R I S T, M D, M S

1. Improving access to naloxone in our communities to reverse overdoses,

2. Expanding access to treatment, especially medication assisted treatment (MAT), and ensuring a pathway to treatment,

3. Preventing prescription opioid drug abuse through appropriate prescribing practices, and

4. Educating Arizonans on the dangers of opioid misuse and abuse.

We all know that minutes count when treating an opioid overdose. Administration of the overdose reversal drug, naloxone, can keep someone alive long enough to get them to an emergency room for life-saving treatment. That’s why increasing naloxone access in our communities is one of our main priorities in combatting the opioid epidemic. We are working to educate families, friends and others at risk of overdosing about the importance of naloxone and the critical steps to take if overdose happens. It is important that those with a loved one who is misusing or abusing opioids talk with their doctor or pharmacist about prescribing naloxone so it is on hand in case of an overdose. Our partnership with AHCCCS, GOYFF, and Sonoran Prevention to get naloxone kits out to the at-risk community has already had a direct impact on our outcomes by reversing over 100 overdoses. Other steps are being taken to ensure those at risk have access to this medication when it counts. By working with AZPOST and law enforcement agencies, we are helping police and firefighter first responders get trained on how to deliver lifesaving naloxone, and to start carrying it with them in the field.

Comments on Opiods

ore than 600 Arizonans died from opioid abuse in 2015, averaging almost two deaths per day. This is an issue that has likely touched your practice and maybe even your family. While acknowledging that even one death because of this scourge is too many, Governor Doug Ducey has made it a top priority to turn the tide of Arizona’s opioid epidemic, challenging his cabinet agencies to reduce the state’s opioid deaths by 150 no later than 2018 and to double this decrease by 2021. To achieve these aggressive goals, the state is applying the same disciplined, data-driven approaches being deployed systematically throughout state government to improve business processes. Indeed, Arizona may be the only state to apply such Lean management methods to address complex social problems like this. Several agencies, led by Arizona Department of Health Services (ADHS), Arizona Health Care Cost Containment System (AHCCCS), and the Governor’s Office of Youth, Faith and Family (GOYFF), are working collaboratively with other regulatory boards and agencies in partnership with stakeholder communities to combine and expand our mutual efforts to address the epidemic. Our work with community partners, such as professional organizations, healthcare providers, public health, and substance abuse coalitions will assist us in achieving the Governor’s goal. The team is actively managing the project for success, adhering to weekly work schedules, routinely tracking performance, and reporting progress to the Governor. We have identified the following four major priorities to address:

“It’s one of the very worst problems in medicine today. EHR is the other.”

Our goal is to have 85% of Arizona’s population covered by first responders who carry and are trained to administer naloxone so this life saving medication is on hand when it matters. Currently, 13 law enforcement agencies statewide are trained to carry and administer naloxone, and we are determined to see this number increase as part of this initiative. Expanding access to treatment is another important strategy. There are currently not enough providers in Arizona to meet existing demand for substance abuse treatment, and we expect the number of patients needing treatment will continue to grow. We are working with healthcare plans and providers to increase the number of MAT providers in Arizona. We are also assisting hospitals, providers and health plans to develop discharge planning guidelines that are evidence-based or promising practices to help get appropriate continuing outpatient treatment for those who present to a hospital with a drug overdose. GOYFF has partnered with the Phoenix Police Department to establish the Arizona Angel Initiative, which allows those who need substance abuse help to present to the Maryvale precinct, turn in their drugs and request treatment without fear of prosecution. We are continuing to develop new strategies to address appropriate prescribing practices as well as increase awareness of the dangers of opioid misuse and abuse among our patient populations. The Arizona Opioid Prescribing Guidelines, released in 2014, are a set of best practices for prescribing opioids using the expertise of practitioners from across Arizona. Using these guidelines to assess, manage, and monitor patients will help prevent misuse and abuse. Free continuing medical education credits are available for providers interested in learning more about the guidelines. Of course, stopping opioid misuse and abuse before it starts is ideal, and we’re focusing on several prevention strategies. Education and awareness campaigns have been implemented around the state including: “I’ve got Something Better,” Rethink Rx Abuse, and “Overcome Awkward.” Pilot projects looking at prevention messaging to middle schools and high schools have been implemented in each county and are showing promising results. And, there is currently a request for grant applications for Arizona high schools interested in participating in the health and wellness grant program, which will support our high schools in creating healthy and drug-free learning environments. In addition, the Governor signed Executive Order 2016-06, which placed an initial fill limitation on opioids to reduce the number of opioid-naïve individuals who are exposed to chronic opioid use. Even with all these activities, there is still a lot to do. Physicians play a critical role in turning the tide on opioid misuse and abuse and we need your help. Here’s what you can do to help stop the opioid epidemic in Arizona: April 2017 | arizonaphysician.com

Doctors, nurses and physician assistants: • Help fill the treatment gap so more people will get the help they need. • This year, become a Suboxone-waivered provider to help us to help meet the demand for opioid treatment in Arizona. An eight-hour buprenorphine waiver training course is required for physicians to prescribe and dispense buprenorphine. Resources and information are available at https://www.samhsa.gov/medication-assisted-treatment/ training-resources/buprenorphine-physician-training.

Prescribers: • Consider non-opioid alternatives when appropriate, and help safely taper patients on dangerously high doses.

Comments on Opiods

“Pharmacists should alert physicians about patients who are receiving multiple controlled prescriptions from multiple physicians.”

• Make sure patients understand the dangers of combining opioids with other medications that could cause an overdose. • Consider co-prescribing naloxone to patients at high risk for opioid overdose. • Utilize the Controlled Substance Prescription Monitoring Program to identify previous opioid use history and assess misuse and abuse risk in your patient. • Know the Arizona Opioid Prescribing Guidelines. • These steps could very well save our patients’ lives. Together we can prevent people from dying and help us achieve the Governor’s goal. Cara Christ, MD, MS is the director for the Arizona Department of Health Services and is responsible for leading Arizona’s public health system including responding to disease outbreaks, licensing health and childcare facilities, operating the Arizona State Hospital, and improving the overall health and wellness of all Arizonans. Dr. Christ also serves as the Governor’s Goal Council chair for Goal Council 3: Healthy People, Places, and Resources.

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ARIZONA PHYSICIAN | April 2017

FREE Opioid Prescribing Online CME Module for Arizona Physicians The Problem

Arizona ranked 15th highest in the nation for drug overdose deaths in 2014, and fifth highest in opioid prescribing in 2011. In response, the University of Arizona Center for Rural Health (AzCRH) and the College of Medicine, Office of Continuing Medical Education (OCME) partnered with the Arizona Medical Association (ArMA) and the Arizona Department of Health Services (ADHS) to provide Drug Enforcement Administration (DEA) certified Arizona prescribers with free, online Continuing Medical Education (CME) case-based modules on acute and chronic pain management using guidelines developed in Arizona and by the Centers for Disease Control & Prevention (CDC).

Background

The Governor’s Office for Youth, Faith and Families; the Arizona Criminal Justice Commission; ADHS; and the Arizona Substance Abuse Partnership launched the Arizona Prescription Drug Misuse and Abuse Initiative in 2012. The initiative includes strategies to “promote responsible prescribing and dispensing policies and practices.”

Response

AzCRH and the OCME developed training modules with funding from ADHS and the CDC. AzCRH, OCME, ArMA, the Governor’s Office, and ADHS work collaboratively to create and market these free online CME modules including Safe and Effective Opioid Prescribing While Managing Acute and Chronic Pain on OCME’s Virtual Lecture Hall website. Additional online CME modules will be made available free to all Arizona DEA-registered prescribers this Summer.

To Access CME Modules or the Guidelines Arizona physicians can access these free online CME modules here: https://www.vlh.com/azprescribing/ Order free copies of the Arizona Opioid Prescribing Guidelines in batches of 10 from Alyssa Padilla, alydilla@email.arizona.edu or Lacie Ampadu, Lacie.Ampadu@azdhs.gov.

April 2017 | arizonaphysician.com

n the last decade, the number of prescription pain relievers sold in the United States increased four-fold with Americans consuming nearly 80% of the global supply of prescription opioids. This has led to widespread opioid abuse and addiction throughout the country. The latest data picture ranks our state as 15th highest in the nation for drug overdose deaths in 2014. While the impact of this epidemic has been devastating, Arizona has been proactive in addressing it head-on. In 2012, Arizona developed the Prescription Drug Misuse and Abuse Initiative in a collaborative effort that included several state agencies, substance abuse coalitions, and other key stakeholders. This initiative is comprised of five key strategies that include: • Strategy 1: Reduce illicit acquisitions and diversion of prescription (Rx) drugs. • Strategy 2: Promote responsible prescribing and dispensing policies and practices. • Strategy 3: Enhance Rx drug practices and policies among law enforcement. • Strategy 4: Increase public awareness and patient education about Rx drug misuse and abuse. • Strategy 5: Enhance assessment and referral to substance abuse treatment. Strategy 2 focuses on encouraging adoption of best practice guidelines, promoting continuing education, and increasing use of the Arizona Controlled Substances Prescription Monitoring System (CSPMP) to prevent prescription drug diversion, misuse, and abuse. Strategy 2 also contains a variety of resources that include the 2014 Arizona Opioid Prescribing Guidelines, Emergency Department Prescribing Guidelines, and Pharmacy Dispensing Guidelines. In addition to these guidelines medical professionals can also take advantage of a free online Continuing Medical Education (CME) course that will allow them to integrate the 2014 Arizona Opioid Prescribing Guidelines into practice. To support the implementation of this work, the Arizona Department of Health Services convened a Rx Initiative Health Care Advisory Team with active participation from the Arizona Medical Association as well as other professional associations. The team meets every other month to provide clinical expertise on developing educational materials and tools, to share best practices, and to engage networks and partners to take action. The team has made recommendations for new CME being

ARIZONA PHYSICIAN | April 2017

Comments on Opiods

“Too much blame is being placed on the medical world for this opioid crisis; originally we were prescribing too little and now we prescribe too much. Society will put the majority of the blame on physicians whichever way the wind is blowing, and that is not right nor understanding of the full picture.”

Promoting responsible prescribing and dispensing policies and practices B Y S H E I L A S J O L A N D E R , M S W & T O M I S T. M A R S , M S N , R N , C E N , F A E N ARIZON A DEPA RTMEN T OF H EA LT H SER V IC E S

April 2017 | arizonaphysician.com

developed by the University of Arizona, and put together a presentation that any health care provider can use to speak to others on the basics of the Arizona Opioid Prescribing Guidelines. The presentation, Arizona guidelines, and other clinical resources are posted at the ADHS Clinicians website, https://azhealth.gov/opioidprescribing. Prescription drug abuse is a public health crisis not only affecting the individual, but the community as a whole. The Arizona Prescription Drug Misuse and Abuse Prevention Initiative provides communities with the necessary tools to join in the fight to end this epidemic and improve the health outcomes of all Arizonans.

References

Prescription Painkiller Overdoses in the US. (2011, November 01). Retrieved March 08, 2017, from https://www.cdc.gov/vitalsigns/ PainkillerOverdoses/index.html

Bates, C., Laciak, R., Southwick, A., & Bishoff, J. (2011). Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice. The Journal of Urology, 185(2), 551-555.

Increases in Drug and Opioid Overdose Deaths – United States,2000-2014. CDC Morbidity and Mortality Weekly Report, December 18. 2015. Poisonings among Arizona Residents 2014.

Resources

Arizona Prescription Drug Misuse & Abuse Initiative Community Toolkit www.RethinkRxAbuse.org Arizona Opioid Prescribing Guidelines www.azhealth.gov/opioidprescribing Prescription Dropbox Locations www.dumpthedrugsAZ.org Suboxone-waivered provider training https://www.samhsa.gov/medication-assisted-treatment/ training-resources/buprenorphine-physician-training Substance Abuse Data www.azhealth.gov/substanceabuse/ Substance Abuse Providers/Resources http://substanceabuse.az.gov/ “Safe and Effective Opioid Prescribing while Managing Acute and Chronic Pain” – Online CME Course www.VLH.com/AZPrescribing

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A Look at the Controversial Removal of Pain as 5th Vital Sign BY DR. UZMA JAFRI

n 1996, the president of the American Pain Society, Dr. James Campbell, stated that if pain were assessed with the same zeal as other vital signs, it would have a much better chance of being treated properly. This sparked a movement among clinicians to aggressively treat pain as a vital sign and the subsequent over-reliance on a new analgesic agent: opioids. These powerful painkillers became the drug of choice at a time when pharmaceutical companies were suggesting that they were less addictive than previously thought, based on a paper that has since been publicly recanted. Fast-forward to August of 2016, when U.S. Surgeon General Vivek H. Murthy, M.D., M.B.A., released a letter about the country’s urgent opioid epidemic and its devastation across communities. Dr. Murthy pointed out that, since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly. Nevertheless, the amount of pain reported by Americans has not changed. Today, nearly two million Americans have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C. Dr. Murthy urged clinicians to take a proactive role in helping to end this epidemic by: • Educating themselves about how to treat pain safely and effectively • Screening patients for opioid use disorder and connecting them with evidence-based treatment • Shaping how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing In the meantime, the American Medical Association (AMA) recently recommended removing pain as a fifth vital sign in hospitals and other settings. Even so, pain continues to be an issue for many people, and managing pain, specifically chronic pain, should continue to be an essential part of any physician’s practice.

Complicating the issue 1. The Centers for Disease Control and Prevention’s (CDC)

recently issued new recommendations strongly advising against the use of opioids for the routine management of chronic pain, shifting focus away from patient-reported pain control toward better controlling the long-term consequences of opioid abuse.

2. The Centers for Medicare & Medicaid Services (CMS)

finalized updated payment rates and policy changes in the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System for calendar year 2017. With regards to pain management surveys, CMS states that, while there is no empirical evidence that purchasing programs unduly influence prescribing practices, they are finalizing the removal of the pain management dimension of the Hospital Consumer Assessment of Healthcare and Systems Survey to eliminate any financial pressure clinicians may feel to overprescribe medications. CMS will continue the development and field testing of alternative questions related to provider communications and pain.

Combined with the CDC guidelines, and despite exempting patients receiving cancer treatment and seriously ill and end-of-life patients, there is growing concern about the potential chilling effect these guidelines and policies could have. Pain relief is a top priority for those with life-limited illness because it can improve quality of life and relieve stress. Significant pain calls for aggressive pain management. Providers and pharmacists must take steps to ensure that strict policies don’t limit access to opioids for the growing population of patients with significant chronic pain during serious and advanced illnesses.

Pain, pain go away In issuing its recommendation, the AMA has swept aside the reason pain as the fifth vital sign was initially put April 2017 | arizonaphysician.com

What can be done? A number of safe and effective pain management strategies exist that can be integrated into the healthcare continuum to combat over-reliance on opioids. An effective strategy typically requires a comprehensive, integrated

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ARIZONA PHYSICIAN | April 2017

approach that incorporates the perspectives of various disciplines and professions, including palliative care. wMore education and training is required so that physician prescribers can gain a comprehensive understanding of how to assess addiction risk factors and manage risk of abuse among opioid-naïve patients. Furthermore, there needs to be greater focus on care alternatives, as well as strategies for establishing safe prescribing practices, as outlined by the CDC, and approaches for communicating the risks of opioids to patients. At the same time, hospitals should invest in providing training programs and other resources for prescribers. In particular, special attention should be paid when patients are discharged and sent home with prescriptions and/or drugs. It is also important to check Arizona’s Controlled Substances Prescription Monitoring Program before prescribing, especially in the emergency department or at the point of discharge. Furthermore, greater emphasis should be placed on programs that provide non-drug options for managing chronic pain, such as behavior modification programs, cognitive therapy and exercise and physical therapy programs. Ultimately, when it comes to dealing with chronic pain, knowledge about the risks of addiction to opioids and alternative treatments will become critical for physicians and patients alike. Dr. Uzma Jafri is a native Texan transplanted to Arizona, where she has established her career and home. She moved to the Valley in 2007 to train at what was Good Samaritan Medical Center in Family Medicine and specialized in Geriatric Medicine at Banner Boswell Medical Center. She has worked as a hospitalist in the Banner system, and has been in private practice providing mobile geriatric service to the West Valley since 2013. Her specialty requires extensive hospice and palliative care experience, and she’s been serving hospice patients in that capacity throughout this time. She is a member of the Arizona Geriatrics Society and The Society for Post-Acute and Long-term Care Medicine. Dr. Jafri also teaches resident physicians and geriatric fellows as faculty at the Banner Family Medicine Geriatric Fellowship, encouraging graduate learners to learn as much as they can about long-term care and hospice. Her personal interests include international relief work, local community service, reading, eating out, and crafting with her four children.

Comments on Opiods

into place: the failure of clinicians to effectively assess pain and the under-treatment of pain in U.S. hospitals. When an emphasis on pain assessment began originally, the point was to ensure the systematic assessment of pain, not that all pain be managed with opioids. The Veterans Health Administration, for instance, recognized the value in including pain as the fifth vital sign in their national pain management strategy. Today, Americans consume 80 percent of the world’s legally prescribe opioids, despite accounting for less than five percent of the world population. This national embrace of opioids has been the result of the entire medical establishment – including governmental, nonprofit, and pharmaceutical organizations – seeking ways to mitigate pain. While taking measures to control what has become a serious public health crisis is important, it must be done without harming patients who rely upon opioids to manage their chronic pain, especially those with cancer, long-term illness and advanced, end-of-life illnesses. Without pain assessment, and with tightened restrictions around the use of opioids, the quality of life and ability to relieve suffering for these patients comes under serious threat.

““We We as Physicians should have moved quicker to self-police this issue. Instead, we have legislators stepping in and this is unfortunate.”

CME: A Bridge to Better Pain Management?

BY CHARLES DASCHBACH, MD, MPH April 2017 | arizonaphysician.com

rizona Governor Doug Duceyâ&#x20AC;&#x2122;s January letter to the Arizona Medical Boards requests that they initiate a requirement of one hour of completed Continuing Medical Education (CME) at biennial physician licensing in the area of addiction or opioid prescribing. Across the medical education continuum, there is clear recognition of how physician education can elicit change and improve patient outcomes. A broad national coalition of the Centers for Disease Control and Prevention (CDC), American Medical Association (AMA), Accreditation Council for Continuing Medical Education (ACCME), state medical associations, and professional medical groups recognize the need for greater education in a complex social equation with physician prescribing patterns contributing one recognized element of the crisis. Primary care, emergency medicine, and pain addiction specialists as well as surgeons are aware of this rising crisis. Specialty boards may now begin inclusion of pain management in Maintenance of Certification (MOC) requirements and Graduate Medical Education (GME) is incorporating addiction into residency curricula. The CDC estimated a new U.S. record of 33,000 opiate deaths in 2015, a total exceeding auto accidents, with heroin-related deaths now more prevalent than gun-related homicides. They also point to an increase of overdoses this past year due to an influx of newer and more powerful synthetic narcotics. To complicate this issue, the current Republican healthcare replacement proposal would eliminate by 2020 the

Specialty boards may now begin inclusion of pain management in Maintenance of Certification (MOC) requirements and Graduate Medical Education (GME) is incorporating addiction into residency curricula. 20

ARIZONA PHYSICIAN | April 2017

1977

2017

Hospice of the Valley offers more than end-of-life care. We work with you. Physicians may continue to care for their patients or choose to have one of our doctors oversee care. Three ways to refer: Call (602) 530-6920 â&#x20AC;˘ Fax (602) 530-6905 Online: hov.org Follow-up will be completed within 24 hours. Staff on duty round-the-clock.

Affordable Care Act (ACA) requirement that Medicaid cover basic drug addiction treatment and mental health services. Some academics estimate that a loss of ACA coverage could adversely impact 222,000 individuals with opioid disorders. The Governor’s 2018 Budget includes positions for five new addiction specialists to help further catalyze and assist our programs. Other recent Arizona efforts included an executive order limiting initial opioid prescriptions for Arizona Health Care Cost Containment System (AHCCCS) and state employees to seven days; legislation to curtail “doctor shopping;” and allowing pharmacists to dispense Naloxone to individuals at risk of overdose and their families. Some Arizona physicians see these moves as an intrusion into physician autonomy and without an accepted evidence base to support the guidelines. Turning back to the Governor’s Continuing Medical Education (CME) request to the Medical Boards, however, there is a recognition that many physicians are uncomfortable with their pain management education. Arizona’s current biennial license requirement of 40 hours is not as specific nor as prescriptive as other states. For example, Massachusetts requires 100 hours every two years with a minimum of 40 hours ACCME / AMA PRA Category 1™, to include three hours of opioid pain management and two hours in end of life care. Texas requires 48 hours, with at least 24 Category 1 credits, and two of these hours must be in medical ethics and professionalism.

The 2015 Arizona Medical Association (ArMA) House of Delegates passed Resolution 11-15, supporting an Arizona license requirement specifying that the 40-hour biennial renewal include at least 20 hours of AMA PRA Category 1™ or equivalent credit. Is there evidence that CME can be effective in improving quality improvement and patient care? How can timely and relevant CME better complement current CME programs and activities – and other community programs directed at improving health outcomes? It raises the question of CME’s ultimate purpose…improving the health of a single patient and of an entire population. Governor Ducey’s request to the Arizona Medical Board and Arizona Board of Osteopathic Examiners may well be an opportunity to reexamine Arizona’s Continuing Education Requirement in toto. Dr. Charles Daschbach is the current chair of the Arizona Medical Association’s (ArMA) Committee on Accreditation and Medical Education (CME Committee), which oversees the accreditation of local CME programs in Arizona. Dr. Daschbach has served on numerous medical education boards, including the Accreditation Council on Continuing Medical Education (ACCME), a national accrediting body for CME programs. ArMA is recognized by the ACCME to accredit local CME programs.

April 2017 | arizonaphysician.com

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Conquering Pain: a Conversation on Team-Based Care with

Patrick W. Hogan, DO BY DOMINIQUE PERKINS

Article Photos by Denny Collins Photography

rowing up, Patrick Hogan, DO, used to visit his mother at work. She was an oncology nurse, and she brought him to the hospital unit to meet her coworkers. To a young boy, the bustling atmosphere and colorful uniforms had an instant appeal, and an interest in the healthcare field was born. Naturally this interest matured as did Hogan. As he progressed in his education, he found a lasting love of science. This, combined with the fond colorful memories of visiting his mother’s hospital fed his interest, while many outstanding teachers and mentors supported, encouraged, and furthered his goals. After graduating from Concordia College in Moorhead, Minnesota, Hogan attended medical school at Midwestern University/AZ College of Osteopathic Medicine, here in

Glendale, Arizona. Our beautiful desert state took hold of Hogan immediately. “During medical school I absolutely fell in love with Arizona. Arizona exposed me to different cultures and a diverse population that I hadn’t experienced while growing up in the Midwest,” he said. After graduating from Midwestern, he moved to Cleveland, Ohio to complete a residency in anesthesiology, and a fellowship in pain medicine at the Cleveland Clinic. But the West had won his heart. “When I moved away to Cleveland to complete my training I thought about moving back to Arizona almost every day,” he said. Once he finished his training, Hogan gladly accepted a April 2017 | arizonaphysician.com

position in Glendale, and has been here for the past eight years. Two years ago Hogan and a partner, Tristan Pico, MD, founded their own practice, AZ Pain Doctors. Hogan currently serves as the CEO. “We are proud that our practice has great patient success by using a multi-disciplinary ‘team’ approach to managing acute and chronic pain,” he said of his group. This multipronged approach includes chiropractic care, acupuncture, interventional pain management procedures, stem cell injections, and medication management. Hogan has great confidence in the team they have put together, and said that each of their physicians graduated from ACGME-approved fellowship and residency programs, and are board-certified or board-eligible in anesthesiology and pain medicine. In light of today’s opioid crisis, this is a growing necessity. Our country is currently facing a prescription crisis, and blame is cast all around. According to the Morbidity and Mortality Weekly Report (2016;65) drug overdose is the leading cause of accidental death in the United States. In 2015, 52,404 instances were reported. While some of these are attributed to other drugs, opioid addiction leads the epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin.

Facing down the issue Managing this crisis, and coming up with solutions for regulation and oversight, are hot-button issues on the minds of governments, group and hospital leadership, and many physicians. As a pain specialist, of course, these issues are very near and dear to Hogan’s practice, and he is taking an active part in facing down the issue. Hogan is currently the CEO of the Arizona Society of Interventional Pain Physicians (AZSIPP), an organization that is dedicated to preserving patients’ access to high-quality and effective pain management care. “Our physicians believe that patients have a right to receive safe and effective pain management care,” Hogan said. Hogan also serves on the Legislative Affairs Committee

of the Arizona Osteopathic Medical Association (AOMA), a position he says intersects with his duties and goals at AZSIPP quite frequently, since both organizations are dedicated to preserving quality medical care. “Currently, AZSIPP members are involved with scope of practice expansion issues and advocating for patients for improved access to interventional pain management,” Hogan said. Organization members recently travelled across Arizona in coordination with medical associations and medical boards to educate providers about the opioid crisis. Others travelled to Washington, D.C., to meet with legislators to encourage ongoing funding of the Controlled Substances Prescription Monitoring Programs (CSPMP). Hogan described the CSPMP database as an integral part of modern daily practice. “Reviewing it prior to opioid prescribing is already our policy at AZ Pain Doctors,” he said. Beginning October 1st, all Arizona physicians may be required to check the database before prescribing. “Unfortunately, the opioid crisis is a very serious problem,” Hogan said. “The research I have read seems to indicate that states which utilize databases, like CSPMP, have seen reductions in opioid abuse.” While Hogan said that his overall experience with the database has been quite positive, he recognized that as a new requirement it may come with its own headaches, or unintended consequences. Because of this, he feels it is important that a mechanism be implemented to gather physician feedback on the system, so that adjustments can be made with a clear vision of the facts.

Prescribing caution In addition to the growing numbers of addictions and fatalities surrounding opioid use, an increasing number of physicians have come under scrutiny, and face possible disciplinary actions for overprescribing opioids. Primary care physicians and others who do not specialize in pain

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ARIZONA PHYSICIAN | April 2017

Dr. Hogan with his wife, Tiffany, and their children.

Managing this crisis, and coming up with solutions for regulation and oversight, are hot-button issues on the minds of governments, group and hospital leadership, and many physicians.

management make up many of these cases. Hogan advises considering non-opioid treatments before any prescription. “If we can reduce “first-time” opioid exposure to patients we will reduce the rates of addiction and abuse,” he said. When opioids are deemed to be the best course of action, Hogan advises short-term prescription treatments, while facilitating referrals to appropriate specialists. Of course specialist referrals can be more difficult in some areas of the state, and in those cases Hogan said it is important to follow the Medical Board guidelines for opioid prescribing. “On those occasions where it becomes necessary to prescribe opiate medications, consideration should be given towards using abuse-deterrent opiates and providing naloxone antidotes for higher-risk patients,” he said. “The Medical Board guidelines are an excellent resource for other best practices in chronic opioid therapy such as urine drug testing, opioid agreements, etc.” Governor Doug Ducey recently implemented an order limiting new opioid prescriptions to seven days for patients who are a part of the Arizona Health Care Cost Containment System (AHCCCS), or otherwise insured through a state employment health plan. As a measure to reduce first-time opioid exposures (and thereby reduce addiction and/or abuse) Hogan said the April 2017 | arizonaphysician.com

executive order has the potential to achieve positive results. Other avenues are being explored to curb the epidemic, he said, and much will come down to the public’s willingness to invest necessary funds into a solution. “I am very impressed in the level of commitment Governor Ducey and our legislators have shown in trying to curb the opioid crisis in Arizona,” he said. “If our community is willing to make some short-term sacrifices, we can reduce the high costs we are experiencing due to opioid abuse long term.”

The research I have read seems to indicate that States which utilize databases, like CSPMP, have seen reductions in opioid abuse. Exploring alternates When approaching pain management in his own practice, Hogan takes a few steps to explore alternatives to opioids with his patients. The first step, naturally, is to ensure an accurate diagnosis through objective data, thorough patient history, and physical examination. “Frequently, I recommend conservative measures such as chiropractic care, non-opioid medications, and physical therapy,” Hogan said. “If those modalities are not successful then appropriate interventional pain procedures are often available as options, as well as opioid medications.” While much is said regarding the detrimental effects of opioid use, Hogan cautioned not to ignore the realities of the flip side. “It is important to note that opiates may play a positive role in patient health, which is why they are prescribed,” he said. “Many patients who are prescribed opiates experience a significant reduction in pain and improvement in their quality of life.” A hot topic in the realm of alternative treatments is the use of marijuana for medical benefit. However, Hogan expressed his opinion that there is not sufficient evidence, currently, to indicate significant pain-reduction in marijuana use. “I need to see more objective data, consistent dosing formulations, medication-interaction studies, and FDA 26

ARIZONA PHYSICIAN | April 2017

approval,” he said. “Once those steps are achieved, I would feel comfortable that the benefits of using marijuana for pain management would outweigh the risks.”

A question of scope The Arizona legislature and medical boards have faced many questions regarding scope of practice in the last few years. There has been a fair amount of talk about Certified Registered Nurse Anesthetists (CRNA) lobbying for expanded practice, including pain management. Hogan described a predominately online nursing fellowship he has seen recently rolled out in Texas, which advertises teaching nurses how to perform x-ray guided spinal injections, as well as other procedures, and to diagnose and treat patients who suffer from chronic pain. Hogan said that he, as well as the AZSIPP, believe that diagnosing and treating chronic pain patients constitutes the practice of medicine, and as such, belongs squarely in the scope of a full medical degree. “Myself, along with colleagues from AZSIPP, are striving to educate our legislators that while the procedures we perform are safe, if unqualified individuals perform them they can be dangerous,” he said. In addition to concerns regarding outright safety and quality of care concerns, there is also worry that without proper and extensive training, practitioners will not know the appropriate indicators to perform a particular procedure, which could result in increasing utilizations and driving up healthcare costs. Chronic pain patients are a particularly vulnerable population, he added, which adds another layer of caution. Dominique Perkins is the Associate Managing Editor for Arizona Physician and serves as the Communications Coordinator for the Maricopa County Medical Society.

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On the personal side..

The Hogan family out for a walk.

1. Describe yourself in one word. Dedicated.

2. What is your favorite food, and favorite restaurant in the Valley?

My favorite food is pizza, and fortunately in Arizona we have many excellent pizza places. Other than pizza, I enjoy a wide variety of ethnic foods.

3. What career would you be doing if you weren’t a physician?

Fortunately, I feel very blessed and can’t really imagine a more satisfying profession than medicine.

4. What’s a hidden talent that you have that most wouldn’t know about you?

I enjoyed playing the piano when I was younger, and I can still knock out a decent version of “November Rain” by Guns N’ Roses.

6. Favorite Arizona sports team (college or pro)?

I spend every weekend following the s, my daughters’ dance class. Currently, the class is comprised of 3 and 4 year-olds and they have a lot of potential.

7. Favorite activity outside of medicine?

During free time, my favorite activity is spending time with my friends and family. Arizona has so much to offer and I love being able to share those experiences with my children. Lately, I have also been focused on exercise to improve overall health and fitness.

8. Family?

I have a wonderful wife, Tiffany, two daughters, Harper and Avery, and son, Hunter. There is never a dull moment in our house because they are ages 2, 4, and 6 months. We are also fortunate to have extended family who reside in the community.

5. Best movie you’ve seen in the ten years?

I am a regular moviegoer and it is so hard to choose just one. My favorite movies are probably comedies, but I enjoy action and drama films as well. April 2017 | arizonaphysician.com

Guests mingled and enjoyed drinks and appetizers before the program. Mindie Factor and Julie Bui had a quick conversation.

Michael Saubolle, PhD, responded to questions after the program.

2017 Public Health Forum Members of the Maricopa County Medical Society gathered together January 26 to enjoy an evening discussing current public health topics particular to Arizona. The Public Health Forum was hosted in the Society courtyard, and sponsored by Sonora Quest Labs. Speakers included Drs. Bob England, John Middaugh, and John Galgiani. Though it was a cool evening, space heaters and warm appetizers provided by Tasteful Events Serving made the night comfortable for everyone. The informative presentations covered valley fever, the Zika virus, and public health systems, statistics, and funding in Arizona. Following the presentations members engaged in an extensive question and answer period. Bringing physicians together across specialties and employment types to share ideas and collaborate on topics like public health and current policy leads to innovative solutions and is something our healthcare environment definitely needs. We are grateful to be a part of bringing physicians together. The event was photographed by Denny Collins Photography, and the full album can be found on the Maricopa County Medical Society Facebook page.

ARIZONA PHYSICIAN | April 2017

Dr. John Galgiani presented on Valley Fever.

Drs. Toroya and Urcuyo chatted at their seats before the speakers began.

MCMSâ&#x20AC;&#x2122; Jay Conyers introduced the nightâ&#x20AC;&#x2122;s speakers and events.

Dr. Diane Petitti participated in the discussion.

Dr. John Middaugh discussed the role of the public health department, and shared key state statistics.

Laura Hamant and Robert Brown enjoy a conversation before the program.

The guests enjoyed the presentations, and contributed to a productive discussion.

Drs. Mills and Thiagarajan mingled by the lantern heaters.

Dr. Tim Kuberski participated in the Q&A following the presentations.

Dr. Bob England gave us an update on the Zika outbreak.

April 2017 | arizonaphysician.com

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ARIZONA PHYSICIAN | April 2017

Opioid Prescribing and Regulation: What Physicians Think BY SHARLA HOOPER

rug overdose is now the leading cause of accidental death in the U.S., with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015. The opioid epidemic is a serious problem in Arizona, and our medical community and policy makers have been working to address it in various ways. We asked physicians to consider these aspects of the opioid crisis in our most recent survey, and we thank those who shared their views and experiences. In 2015, more than 600 Arizonans died from opioid abuse. One of our medical student respondents saw the effects first-hand: “…it seemed a majority of cases I saw during my medical examiner rotation were deaths from opioid overdose.”

Pain as the fifth vital sign...patients as customers Current policy at the Centers for Medicare and Medicaid Services (CMS) provides hospitals with incentive payments based on patient satisfaction surveys related to how well they felt their pain was controlled. While 26.7% of respondents agreed with the policy but also felt it contributed to overprescribing of pain medication, 59% disagreed with the policy altogether. Several respondents felt strongly that this policy is a contributing factor to overprescribing opioids. “I believe adding ‘pain’ as a vital sign and patient satisfaction scores has turned medicine from the practice of treating patients to the business of keeping customers happy which in the majority of cases is heavily linked to patient’s perception of how their pain was managed. This is ultimately detrimental to both the patient’s well-being and the physician’s ability to treat them objectively without the influence of how they will be rated after each encounter.” And one respondent saw correlation between the impetus of opioid overprescribing and the intervention: “The powers that be who mandated treatment of pain as the fifth vital sign and admonished doctors for their heartless behavior are the same geniuses who now feel that they need to regulate physician-patient relationship again in pain management.”

Regulatory intervention In considering regulatory interventions being implemented, physician respondents were wary. Based on the

respondent comments, this is related to retaining physician autonomy in making the determination for themselves, rather than at the behest of government regulation or statute. As one respondent stated, “I’m leery of any ‘requirements’ made by politicians and non-physician led healthcare companies. I do not think I like the idea of limiting any physician’s prescribing abilities simply because of what type of physician they are. Physician autonomy should be respected and the doctor-patient relationship held to the highest ethical standards while maintaining this autonomy.” Asked about the executive order that instructed AHCCCS (Arizona’s Medicaid program) to establish new guidelines limiting initial opioid prescriptions to seven days for all employees on the state’s insurance plan and all AHCCCS patients, the responses indicated a conflict. 31.1% agreed with the guidelines but had concerns; 41.7% did not agree with the guidelines and felt the decision has a detrimental impact on the doctor-patient relationship. One respondent stated, “Most physicians who prescribe opioids do so in an ethical and appropriate manner and don’t need politicians second-guessing their prescribing practices.” Others saw this as an action punishing many for the actions of a few: “…providers who are identified as high prescribers should be monitored more closely rather than instituting more regulations on everyone. We are already overburdened with extra work and monitoring.”

The role of education Given general misgivings about medical education mandates by government, it was somewhat surprising to see 63.4% of respondents agreed that opioid-related continuing medical education (CME) should be required, either for all licensed physicians, or for all physicians with DEA licenses. Several respondents identified a dearth in drug addiction education for physicians. “I worked for a drug rehabilitation detoxing patients prior to medical school. Once I went to medical school and as a resident, I quickly learned how little physicians know about drug use and abuse. There needs to be more mandated education and it needs to start at the medical school level.” An educator stated, “I review opioid prescribers for the authorities, and am only given 1 1/2 hours to teach opioid prescribing to U of A med students in their four-year program. More intense education is needed.” The current request of Arizona Governor Ducey is that April 2017 | arizonaphysician.com

Do you agree with the policy to incentivize hospitals based on patient satisfaction related to pain control and do you think it contributes to overprescribing opioids?

100

59.0% 26.7%

Do not agree with the incentive policy

Agree with policy and agree it might contribute

7.6% 6.7%

Not sure

Mandated reporting in CSPMP

Agree with policy but do not agree it contributes

Which physicians should prescribe opioids?

7.7%

No physicians

79.8%

All physicians

Not sure

3.8%

6.7%

Only those specializing in pain management

1.9%

Only specialty care physicians

What precautions should physicians take when prescribing opioids to mothers with children living in the home?

76.9%

Physicians should provide additional literature and counseling to the mother

6.7%

Physicians should prescribe alternative therapies

5.8% 10.6%

Physicians should not be concerned

Not sure

ARIZONA PHYSICIAN | April 2017

the Arizona Medical Board establish a required one hour of CME for the biennial physician licensing term, which requires a total of 40 hours of CME. One respondent felt strongly that this was inadequate: “I also hold an active California license and have been required to complete a mandatory 15 hours of CME on pain management focusing on opioids in order to keep my license even though I do not have a DEA number and do not prescribe opioids. One hour of CME is inadequate to bring physicians to a level of knowledge where they should continue… to prescribe opioids. They need 30 hours. The epidemic of opioid deaths in Arizona is real and it is caused by physicians’ irresponsible prescription of opioids.”

Asked about mandated reporting of opioid prescribing in the Arizona Controlled Substance Prescription Monitoring Program (CSPMP), 45.2% of respondents thought it should be mandatory, but in our comments, there were numerous statements indicating that pharmacies are the key point of tracking opioid prescriptions, because that is where they are filled: “I believe a more efficient place for tracking prescriptions is with the pharmacies rather than asking the providers to register each opioid prescription.” And as one respondent pointed out, more documentation regulation requirements are not welcome: “Prescriptions should be registered by pharmacists and dispensing bodies not by physicians or their practices. Too much regulation documentation already trickles up to be dumped on increasingly data entry doctors.” One physician pointed out that effective communication with pharmacists is already making a difference: “Assistance from our pharmacy colleagues in notifying us of patients receiving opioids from multiple sources is the most helpful support I have experienced.” Deficiencies in the CSPMP technology must be addressed to facilitate its use. As one respondent stated, “… it is critically important for any PMP to focus on integration with physicians’ computer systems by providing a web interface using modern, standardized technology rather than individual system integrations.”

Treating chronic pain A number of pain specialists shared their concerns as well, pointing out that regulations are swinging the pendulum too far the other way: “Pain patients are treated like criminals. Those with chronic pain have to worry every month about availability of needed meds. We’re throwing out the baby with the bath water.” There was clear concern for patients struggling with chronic pain and how regulations could affect their care: “Pain is a complex syndrome. There is a clear difference between acute vs. chronic. Making limitations across the board limits clinical syndrome needs.”

Several responses pointed out the importance of distinguishing between short-term acute pain management and chronic, long-term pain management. “Most…cases of overdose are related to prescriptions written for an acute injury like surgery and not from patients who are using opioids to control their chronic pain.” “It’s important not to make it impossible for patients with chronic pain to access a therapy that is effective for an individual. There should be stricter guidelines for short term prescriptions and in certain situations like for control of post-op pain.” However, as one physician stated, “Unfortunately, those two issues are often treated the same by our politicians. For example, A.R.S. 36-2606 only allows ten days for recovery from surgery, which is often an inadequate period of time.”

Inadequacies of healthcare and support systems Respondents also had concerns about the lack of prevention systems and addiction resources in the existing health care system. One respondent stated, “A significant percentage of patients’ first exposure to opioids is for post-op pain control. Enhanced Recovery programs and multimodality pain control should be required in all hospitals, in the same way in which enhanced recovery was mandated in the UK by the NHS several years ago. The USA is far behind on this issue.” Asked about the statistic of increased overdoses by children in homes with opioid prescriptions, 76.9% felt that physicians should take extra caution in prescribing opioids to mothers with young children in the home by providing additional literature and counseling to the mother. One respondent was deeply concerned by the “Demonizing [of] pregnant women” and that removing children “from homes, placed in foster care, is incredibly detrimental to children, families and society. Opioid abuse should be prevented and treated, not criminalized.” Another respondent shared that in their experience, problems encountered in patient care include the fact that the use of alternative therapies such as pain creams have shown results, have no diversion issues and less chance of abuse, but are not paid by insurance plans. Additionally, “The patients need Psych Counselling at the time of prescriptions,...not paid by Insurance Plans at the PCP or Pain Clinics.” One respondent offered a profoundly simple observation, and a reminder that a simple DEA designation paired with Suboxone training can make all the difference: “I am working in a Recovery Center on Indian School Ave. and see the desperate need for Addiction services. My “X” DEA designation allows Suboxone Rxing. It is a life saver.” Sharla Hooper is the Managing Editor for Arizona Physician and serves as Associate Vice President of Communications and Accreditation for the Arizona Medical Association.

Do you agree with the mandated opioid-related CME to renew medical licenses?

36.5% YES

26.9%

YES, but only for DEA licenses for dispensing schedule II drugs

32.7% 3.8% NO

Not sure

Should physicians be required to register all opioid prescriptions using the CSPMP?

45.2% YES

7.7%

YES, for first-time prescriptions only

30.8% 16.3% NO

Not sure

Do you agree with Arizona’s substance abuse program for prison inmates with opioid addiction?

37.9% YES

28.2%

YES, but have concerns

11.7% 22.3% NO

Not sure

Do you agree with the new guideline limits for initial opioid prescriptions to 7 days for state insurance plan and AHCCS patients?

22.3% YES

31.1%

YES, but have concerns

41.7% 4.9% NO

Not sure

April 2017 | arizonaphysician.com

Navigating Compliance and Liability Risks Related to the Management of Chronic Pain B Y K A R E N W R I G H T, R N , B S N , A R M , C P H R M

ain management is a professional liability risk. Data from 2013 revealed almost two million Americans abusing or dependent on opioids and more than 16,000 deaths involving an opioid pain reliever overdose.1 Physicians are liable for failure to appropriately treat pain. Misconceptions and lack of knowledge often contribute unnecessarily to patient and family debilitation and suffering from inadequate or inappropriate pain treatment. On the other hand, a lack of understanding of addiction also contributes to inappropriate pain management. Policy barriers and regulatory scrutiny are often cited as a deterrent to the healthcare professionalâ&#x20AC;&#x2122;s ability to prescribe appropriate pain treatment. Since 2000, the national rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin).2 Arizona state allopathic and osteopathic boards established guidelines for prescribing controlled substances for treatment of chronic pain. Common to all guidelines is the premise that physicians and other healthcare practitioners have a duty to relieve 34

ARIZONA PHYSICIAN | April 2017

pain and suffering. Where a duty exists, failure to carry out the duty is by definition, negligence or malpractice. The increased awareness and emphasis on chronic pain management has raised the level of quality care expectations for both primary care and specialty physicians as well as broadened the scope of professional liability. Prescribing controlled substances for patients with chronic pain consists of several essential components: pain assessment, treatment plan, informed consent, ongoing assessment, consultation, documentation and compliance with controlled substance laws and regulations. Medical boards have made it clear all such prescribing must be based on clear documentation of unrelieved pain and in compliance with applicable state and federal law. Prescription opioid sales in the United States have increased by 300% since 1999, but there has not been an overall change in the amount of pain Americans report.3 Many states including Arizona, Colorado, Nevada and Utah have established controlled substance prescription monitoring programs to track and collect data from retail and outpatient pharmacies and physicians who are licensed

to dispense Schedule II, III, and IV drugs. The data collected can then be accessed by healthcare practitioners and pharmacists to gather information about the patients they serve and to ensure their prescribing and dispensing is appropriate. This information can assist in determining whether the patient is taking the medication appropriately or making other uses of it. Strategies to reduce regulatory and liability risks: • Believe the patient. Pain is a subjective experience. It is what patients say they feel. • Consistently obtain and document a pain history using standardized and quantifiable pain assessments. • Determine the etiology of the pain and document your thought process when recording the differential diagnosis. • Reevaluation of chronic pain patients should be done at least quarterly or as frequently as necessary. A yearly complete reevaluation including repeat diagnostic tests or referrals is prudent. • Develop an individualized plan of care including persons from multi-disciplines as necessary. • Refer to or consult with a pain specialist. • Follow-up on referrals or diagnostic tests. Patients who temporarily “feel better” or are seeking opioids may not follow through, leading to a delay in diagnosis and timely treatment. • When choosing medication, consider an appropriate analgesic class from the World Health Organization Analgesic Ladder or other published pain management guidelines. • Ensure prescriptions for chronic pain management are written judiciously. There are circumstances in which the use of a written agreement between physician and patient outlining patient responsibilities may be necessary for safe and responsible opioid prescribing. Such an agreement should include: – urine/serum medication levels and baseline screening when requested; – number and frequency of all prescription refills; – reasons for which drug therapy may be discontinued; – require the patient receive all controlled substance prescriptions from one physician and one pharmacy whenever possible. • Action is required if the patient violates the pain agreement which may include withdrawal from the patient’s care. • Review the patient’s profile on your state’s controlled substances monitoring database before prescribing Schedule II, III or IV drugs, and then on a regular basis, such as quarterly or at least every six months. • Document all patient contacts, including phone calls regarding pain complaints in a timely and accurate manner. • Document patient non-compliance with recommended protocols in an objective manner and detail attempts at patient education to improve adherence. • Ensure informed consent is obtained and documented prior to the performance.

Ms. Wright is a registered nurse and received her Bachelor of Science in Nursing from the University of Arizona. Ms. Wright earned her Associate in Risk Management and is a Certified Professional Healthcare Risk Manager. She is a member of the American Society of Healthcare Risk Management and is a past-president of the Arizona Chapter. Resources 1 Lipari, R, Kroutil, LA, Pemberton, MS. NSDUH Data Review: Risk and protective factors and initiation of substance use: Results from the 2014 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Administration (SAMHSA) 2015 Oct. Retrieved from https://www.samhsa.gov/data/sites/default/files/ NSDUH-DR-FRR4-2014rev/NSDUH-DR-FRR4-2014.pdf Centers for Disease Control and Prevention. Increases in drug and opioid overdose deaths — United States, 2000–2014. 2016 Jan 1. MMWR 2015; 64:1-5. Retrieved from https://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w

Centers for Disease Control and Prevention. Vital signs: Overdoses of prescription opioid pain relievers - United States, 1999-2008. 2011 Nov 4. MMWR 60(43); 1487-1492. Retrieved from http://www. cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w#fig2 .

Further reading Centers for Disease Control and Prevention. Injury prevention & control: Opioid overdose. Drug overdose death data 2013-2015. 2016 Dec 16. Retrieved from https://www.cdc.gov/drugoverdose/ data/statedeaths.html

April 2017 | arizonaphysician.com

or over forty years, the Arizona Center for Law in the Public Interest has been using legal advocacy to address issues that affect the public in a number of important areas including: access to health care for children and adults, defending the rights of disabled children in public schools, ensuring equitable school financing, protection of the environment and many others. One area that the Center has continuously focused on since it was established in 1974 is access to health care. Just last month, Center attorneys were in court defending Arizona’s Medicaid Expansion Program that was enacted in 2013. Legislators voting against the expansion sued the state claiming that the hospital assessment authorized by the legislature constituted a tax that required a two-thirds legislative vote under Arizona’s Constitution. In 1981, the Center filed a class action lawsuit on behalf of indigent individuals with serious mental illness. We argued that state law required the legislature to establish community based services for the seriously mentally ill. In 1989, the Supreme Court agreed. We spent years to induce compliance with the Court’s decision. Those efforts culminated in a final resolution of the case in early 2014 which included expanded capacity for community based mental health services for thousands of people with mental illness and included provisions for assertive community treatment, supported housing, supported employment and peer and family support services.

Since 1974, the Center has established a track record of holding government accountable when it fails in its duties to protect the public health of its citizens. In 1991, we filed a lawsuit on behalf of Medicaid eligible children entitled to mental health and substance abuse treatment services. Ten years later, we reached a settlement with the state that reformed the state’s behavioral health care system for children. The settlement was unique in its approach to reform because it spelled out in a legal document a “vision” defining the purpose of children’s behavioral health services and a set of 12 principles for improving the quality of those services to be incorporated in all aspects of the system’s operations. When the Great Recession hit, the Arizona legislature eliminated AHCCCS eligibility for very low income individuals without children. The Center stepped in to try to stop what it thought was an unlawful attempt by the

ARIZONA PHYSICIAN | April 2017

Defending Public Access BY ANNE RONAN

April 2017 | arizonaphysician.com

legislature to nullify Proposition 204 which had increased AHCCCS eligibility for low income individuals whose income fell below 100% of the federal poverty level. We were not successful in stopping the cuts which resulted in the loss of health care for over 150,000 Arizonans. However, the Court’s determination that the legislature was required to provide the supplemental funding necessary to extend healthcare to all eligible individuals laid the groundwork for the Governor’s support for Medicaid expansion in 2013. The expansion has provided health care to hundreds of thousands of low income Arizonans. In 2015, the Center filed a lawsuit on behalf of foster children. The case was filed on behalf of a class of children in the custody of the state who are not receiving necessary medical services and mental health treatment. These children are routinely separated from their siblings and bounced around from one institutional setting to another and regularly denied medical and behavioral health services that they desperately need. If successful, this lawsuit will improve the lives of over 18,000 children in state foster care. The Center’s efforts in the public health arena include the enforcement of the Clean Air Act. That Act was intended to improve the health of all Americans by reducing air pollution. The Act set national air quality standards and requires corrective plans from areas that do not meet those standards. One of those areas was Phoenix. The Center filed numerous citizen enforcement actions over the years to require meaningful implementation plans to reduce

ozone, carbon monoxide and particulate pollution. Those lawsuits have almost all been successful and have played an important part in moving the Phoenix metropolitan area into compliance with the clean air standards. Since 1974, the Center has established a track record of holding government accountable when it fails in its duties to protect the public health of its citizens. It stands ready to collaborate with the physician community to identify important public health issues and develop strategies to address them. The Center is a non-profit public interest law firm. It has a staff of three dedicated lawyers and is governed by a Board of Directors. Over half of its budget comes from individual contributions made by supporters throughout the state. If you’re interested in reading more about, or supporting, the Center’s work you can do so on its website at www.aclpi.org. Anne Ronan has been an attorney with the Arizona Center for Law in the Public Interest since 2004 focusing on public health issues. She has been practicing in the area of health law for the poor and uninsured since graduating from Arizona State University College of Law in 1979 and previously worked with Community Legal Services and the Arizona Center for Disability Law.

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Combatting the Opioid Epidemic

B Y M A R YA N N DAV I E S , O M S I I I

April 2017 | arizonaphysician.com

he neonatal intensive care unit (NICU) at Tucson Medical Center (TMC) has a special room for newborns recovering from opioid withdrawal. This room is a relatively new addition to the TMC NICU, and to me represents the growing issue of opioid addiction in our communities. During my NICU rotation I remember a distinctive moment, holding one of those trembling newborns in my arms and thinking about the innocent lives affected by the growing opioid epidemic. As a medical student, I found myself trapped by the feeling of helplessness at the foot of a seemingly insurmountable nationwide problem. Later that week, I attended a lecture by a pain specialist about opioid addiction. He introduced the topic as “one of the greatest mistakes in medical history,” with health providers playing a pivotal role as prescribers1. The Centers for Disease Control and Prevention (CDC) published guidelines for prescribing opioids for chronic pain as part of a federal effort to address the opioid epidemic2. However, in doing this, the CDC propagates the message that physicians are responsible for the nationwide crisis and must be monitored by governmental forces. Perhaps instead of proliferating sentiments of blame and guilt among patients and providers, a progressive outlook that fosters collaboration, teamwork, and initiative would be a much more constructive approach. Encouraging physicians to be champions of change is essential for shifting the

present trajectory towards patient dependency, addiction, and mortality due to opioids. Similar to the concept of antibiotic stewardship to prevent the development of multi-resistant pathogens, we need to promote a culture of opioid stewardship, where prescribers recognize the greater impact opioid use has on society. Additionally, implementing an interdisciplinary approach can empower physicians and patients with alternative or supplemental resources for managing chronic pain such as physical therapy, osteopathic manipulation, chiropractic adjustment, acupuncture, social work, and behavioral health services. Physician leadership is imperative for educating current and future health care providers about managing patients with chronic pain and opioid dependency. For patients ready to seek help and pursue long-term addiction recovery, it is important to be familiar with structured treatment programs that incorporate counseling and medication management. Maintaining a non-judgmental perspective will help build a trusting patient-provider relationship and improve care of patients affected by opioid dependency. While there is no easy solution to the complex issues surrounding the opioid crisis, physicians must not lose sight of their capacity to make a difference. As key members of the medical community, we can work towards building a health care culture that focuses less on treating pain and more on promoting wellness. For example, rather than assessing a treatment’s effectiveness based upon arbitrary

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ARIZONA PHYSICIAN | April 2017

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While there is no easy solution to the complex issues surrounding the opioid crisis, physicians must not lose sight of their capacity to make a difference.

Maryann Davies is a third year DO and MPH dual degree student at A.T. Still University, School of Osteopathic Medicine in Arizona (ATSU-SOMA). She is interested in public health advocacy for underserved populations and humanistic, patient-centered care in medicine. During her first two years of medical school, Maryann served as a Student Ambassador and Co-Chair for the Latino Medical Student Association Chapter at ATSU-SOMA. She is a member of the national Gold Humanism Honors Society and Sigma Sigma Phi osteopathic service fraternity. She aspires to continue promoting wellness through cultural competency, education, and mentorship throughout her medical career. References

pain scale ratings, a provider might ask about how a patientâ&#x20AC;&#x2122;s symptoms are impacting his or her ability to perform activities of daily living and function in everyday life. Thus sparks the beginnings of a transformative movement in health care that converts a nationwide crisis into a momentous opportunity for enhancing the quality of patient care in our communities.

Scott, P. (2016.) Reliance on opioids: One of the greatest mistakes in medical history. Star Tribune. Retrieved from: http://www. startribune.com/reliance-on-opioids-one-of-the-greatest-mistakein-medical-history/375906361/

Dowell, D., Haegerich, T., & Chou, R. (2016.) CDC guideline for prescribing opioids for chronic pain. Morbidity and Mortality Weekly Report Recommendations and Reports. Retrieved from: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1. htm#suggestedcitation

April 2017 | arizonaphysician.com

The Sonoran Prevention Works staff after training correctional health staff at Lower Buckeye Jail in Phoenix.

ARIZONA PHYSICIAN | April 2017

A box of naloxone kits ready to be picked up by a community distributor.

Sonoran Prevention Works BY HALEY COLES

n the midst of an increasing drug abuse epidemic, one Arizona nonprofit is embracing some unconventional tactics. We are called Sonoran Prevention Works (SPW), and we operate from a harm reduction framework to improve the lives of people who use drugs and their communities. After advocating for the passage of HB 2355 in 2016 to expand accessibility to the overdose reversal medication naloxone, SPW began distributing naloxone through a standing order to high-risk opioid users and their family members in September of 2016. Just in the last four months of 2016, we distributed 1,340 kits in Maricopa county and received 394 reported uses of the medication. In 2015, over 1,200 Arizonans lost their lives to an overdose. Because of this unacceptable statistic, SPW and Arizona Health Care Cost Containment System (AHCCCS, the Arizona Medicaid program) partnered at the beginning of 2017 to expand naloxone accessibility statewide. We received support to distribute free naloxone to Arizonans at risk of an overdose, or those who may be in a position to assist in the event of an overdose. SPW is now tasked with reaching every county and reservation in the state by the end of the year. In addition to distributing naloxone, we are working with community partners in each region to assist in developing their own

programs, policies, and procedures surrounding overdose prevention education, naloxone prescribing, and when appropriate, naloxone dispensing. As a small organization with only three paid staff, we rely wholeheartedly on community members to become leaders in the fight against accidental overdose. We train and certify community distributors to teach locals about overdose prevention and naloxone use. Once trained, these community distributors can also dispense naloxone to their community members. SPW has trained community members and distributed naloxone in Maricopa, Pima, Yavapai, Cochise, Gila, Graham, Navajo, Mohave, and Coconino counties, and on the Salt River and Pascua Yaqui reservations in the first three months of 2017. Recipients vary from active opioid users, to law enforcement, to family members, to taxi drivers. Since the beginning of our naloxone distribution program in September 2016, SPW has distributed over 5,600 naloxone kits and received 494 reported uses of naloxone to revive an overdose victim. Concerns have arisen that naloxone availability is only a band-aid for a complex social problem, and in some sense this is true â&#x20AC;&#x201C; but it is working to stop the bleeding of a gushing wound. Naloxone accessibility does not serve necessarily to end opioid abuse, but it does give Arizonans April 2017 | arizonaphysician.com

a chance at surviving a preventable and tragic death, therefore giving them the opportunity to receive support and assistance to make positive changes. It is important to acknowledge that the majority of opioid overdose deaths in the state are a result of prescription opioid pills, and the age group that is being hit hardest is ages 45-54. Accidental death by opioid overdose can no longer be solely characterized by the image of a young IV heroin addict; we are also seeing older individuals unknowingly taking too many prescribed pills, people mixing their pills with alcohol, and Arizonans who unintentionally became dependent on pills that were prescribed to them for

Haley Coles,executive director for Sonoran Prevention Works, founded the organization in 2014, but has been working to improve health equity for people who use drugs in Arizona since 2006. She has been recognized for her achievements by Governor Ducey in Arizona and Governor Inslee in Washington. She looks forward to moving to rural Arizona in the next five years and building an adobe house. She can be reached at hcoles@spwaz.org. Learn more about Sonoran Prevention Works at spwaz.org.

Governor Doug Ducey congratulates SPW Executive Director Haley Coles on the lives saved through their overdose prevention program.

Comments on Opiods

â&#x20AC;&#x153;I think that with all of the data available on physician narcotic prescribing it should not be that difficult to find and deal with the physicians that are over and/or inappropriately prescribing narcotics.â&#x20AC;?

a legitimate purpose. Opioid dependence and overdose does not discriminate, which is why naloxone accessibility is so crucial to stem the tide of preventable death. Studies have shown that those at highest risk of an accidental overdose are those leaving abstinence-based treatment, jail, or prison. People who have had one accidental overdose are also at higher risk to experience another one compared to those who have never overdosed. That is why SPW is targeting treatment centers, jails, and emergency rooms across the state to assist in educating patients on opioid use risk management and dispensing naloxone whenever possible. Patients are encouraged to teach their friends and family how to use the naloxone they receive in case the patient experiences an overdose. Those patients may also have the opportunity to use their naloxone on somebody else. According to the CDCâ&#x20AC;&#x2122;s report on community-based naloxone programs between 1996-2014, 83% of overdose resuscitations with naloxone were performed by people who use drugs. In addition to saving lives, empowering people who use drugs to save a life has been shown to improve self-esteem and actually reduce drug use. Naloxone gives service providers the ability to build relationships with some of our most vulnerable citizens by talking truthfully about opioid use and affirming the right to life for those who use opioids both legally and illicitly. SPW is working hard to build capacity among Arizona agencies and bring opioid users out of the shadows. Overcoming stigma is an uphill battle, but one that is becoming a little easier due to overwhelming support for opioid prevention programs and naloxone availability. Thanks to the partnerships forged throughout the state, we are reducing preventable death and giving Arizonans another shot at life.

Arizona Physician (USPS 020-150) is published 12 times per year. It is a combined publication of the Arizona Medical Association, Maricopa County Medical Society, and Pima County Medical Society, 326 E Coronado Rd., Phoenix, AZ 85004. Periodicals postage paid at Phoenix, AZ. Postmaster, send changes to: Arizona Physician, 326 E Coronado Rd., Phoenix, AZ 85004. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights reserved. Volume 1, Issue 4

ARIZONA PHYSICIAN | April 2017

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