March/April 2017 - Addiction

March/April 2017

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Addiction

In This Issue: • • • •

Physicians Serving Physicians TCMS Holds Annual Meeting Patricia Walker, M.D. Receives Shotwell Award Luminary of Twin Cities Medicine

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves.

Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 19, NO.2 MARCH/APRIL 2017

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IN THIS ISSUE

Addictions: Our Worst Health Problem

By Robert R. Neal, Jr., M.D.

4

PRESIDENT’S MESSAGE

Challenging Conversations By Matthew A. Hunt, M.D.

5

TCMS IN ACTION By Sue Schettle, CEO ADDICTION

Page 32

6

•

Physicians Serving Physicians

By Annie Burton, M.D.

9

•

Who Needs the Health Professionals Services Program?

By Monica Feider, MSW, LICSW

11

•

Colleague Interview: A Conversation with Charles Reznikoff, M.D.

15

•

MN Law Soon to Require Prescribers to Register for Access to the Minnesota Prescription Monitoring Program Database

By Dr. Cody Wiberg and Barbara A. Carter

18

•

SPONSORED CONTENT:

A Proactive Approach to the Opiate Prescription Crisis with Compassionate, Patient-Centered Care

By Alfred L. Clavel Jr., M.D. and Beth Averbeck, M.D. Page 30

20

•

Should Sugar Be Considered a Dangerous Drug?

By Robert H. Lustig, M.D., M.S.L.

22

•

SPONSORED CONTENT:

Help for Adolescents With Co-Occurring Disorders

By Diana Chapa, M.D. •

Long-Term Risk with Cannabinoid Therapies: Considering Rhetoric, Science and Compassionate Care

By Gary Starr, M.D. March/April 2017

24

26

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Co-Occurring Posttraumatic Stress Disorder and Opioid Use Disorder Among Military Personnel

By R. John Sutherland, Ph.D.

28

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Environmental Health — Addicted to Oil?

29

Matthew Hunt, M.D. Installed as TCMS President

30

Patricia F. Walker, M.D., DTM&H, FASTMH Receives Shotwell Award

Page 29

Career Opportunities

32 Page 29

MetroDoctors

LUMINARY OF TWIN CITIES MEDICINE

Mark L. Willenbring, M.D. The Journal of the Twin Cities Medical Society

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Addiction

In This Issue: • • • •

Physicians Serving Physicians TCMS Holds Annual Meeting Patricia Walker, M.D. Receives Shotwell Award Luminary of Twin Cities Medicine

Managing pain while preventing addiction is a challenge; early intervention is key. Articles begin on page 6.

March/April 2017

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Stephanie Misono, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Mac Garrett Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Emily Larsen

March/April Index to Advertisers

TCMS Officers

President: Matthew A. Hunt, M.D. President-elect: Thomas E. Kottke, M.D. Secretary: Andrea Hillerud, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Carolyn A. McClain, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com

Clearway................................................................. 7 Crutchfield Dermatology.....................................

Inside Front Cover Entira Family Clinics .......................................31 Fairview Health Services .................................30 Hazelden Betty Ford Foundation.................31

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Healthcare Billing Resources, Inc. ...............10

Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

M Health .............................................................16

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

HealthPartners Institute ..................................12 Minnesota Adult & Teen Challenge ...........14 MMIC ................................ Outside Back Cover Physician Advocacy Network .......................... 8

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

Grace Higgins, Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com

PrairieCare ...........................................................27

Annie Krapek, Assistant Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

Saint Therese.......................................................10

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

Pamela Palan, Project Manager, The Convenings (612) 362-3724; ppalan@metrodoctors.com

Helen Nelson, Administrative Assistant, Honoring Choices Minnesota (612) 362-3705; hnelson@metrodoctors.com

PrairieCare PAL .................................................17 St. Cloud VA Medical Center ............................

Inside Back Cover Uptown Dermatology & SkinSpa.................. 2 U.S. Army Health Care Recruiting .............28

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

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March/April 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Addictions: Our Worst Health Problem

T

hree of the top 10 “biggest health problems” listed by the CDC are addictions — alcohol, opioids, and tobacco. Substance abuse costs our nation yearly over 166 billion in health care dollars and $700 billion overall. Unfortunately, we physicians have been complicit in the misuse of opioids since one half of opioid overdoses are due to prescribed pain medications. Since 2000, over 300,000 Americans have died from opioid overdoses. Opioid abusers seem to fall into two age groups. The under 40 group is more apt to use heroin because it is cheaper and more available than prescription drugs while the over 40 age group tends to use Rx drugs as they are more available to treat their “conditions of age.”

Our first two articles deal with how addicted physicians (15% of us during our practice years) can overcome their abuse problems. Physicians Serving Physicians (PSP), founded in 1981, is an independent, privately-funded organization that assists substance abuse affected physicians with identification, intervention, education, and treatment resources. Their services are confidential provided agreed upon guidelines are met. Health Professional Services Program (HPSP) was established by the legislature in 1993 to address providers who are deemed impaired, provides monitoring and facilitates treatment. The good news is that the recovery rate for physicians is 80% — much higher than other categories.

Our colleague interview is with Dr. Charles Reznikoff. The discussion brings out many pearls of wisdom for management of chronic pain and opioid use. He feels that 1) opioids are not a treatment for chronic pain; 2) it is unsafe to combine opioids with benzodiazopenes; 3) the addictive potential of a medication should be discussed with the patient before its first refill; and 4) physicians that prescribe more than an occasional opioid should consider a license for buprenorphine use.

Dr. Cody Wiberg and Barbara Carter from the Minnesota State Pharmacy Board, provide an informative overview of the Minnesota Prescription Drug Program. This program allows physicians to check on a patient’s controlled drug history as well as their own DEA number’s use. One can also access similar information from other states.

Drs. Alfred Clavel and Beth Averbeck from HealthPartners discuss their current programs to manage chronic pain and lessen opioid addiction — in particular, the neural addiction mechanisms and the management of the “whole patient” by the use of

By Robert R. Neal, Jr., M.D. Member, MetroDoctors Editorial Board

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The Journal of the Twin Cities Medical Society

inter-disciplinary treatment with a proactive platform.

While we do not deal with tobacco or alcohol addictions in this issue, we recognize that they are our two biggest health problems. Since one in six Americans smoke, it is our most costly abuse, and alcohol is our most common substance abuse.

Pornography addiction is a major problem as well.

Newer research and media articles emphasize the reality of sugar addiction and that it should be ranked near the top of the list. I first became acquainted with the importance of the sugar saga through a podcast on food addiction from the Commonwealth of CA. I solicited our article on sugar addiction from Dr. Robert Lustig, a member of that panel, who has written extensively on the subject.

Diana Chapa, M.D. provides us with a discussion of adolescent co-occurring abuse disorders. She states that 23% of adolescents have a substance abuse problem by age 18 and of these 50% are co-disorders. Provided are screening tools as well as intervention and treatment methods.

The 2015 approval of the medical use of cannabis in Minnesota has brought about many questions about its indications, availability, effectiveness and safety. Dr. Gary Starr’s article discusses the history, the use and disuse of cannabis.

Post Traumatic Stress Disorder (PTSD) awareness has been steadily increasing over the past decade. Our article by Dr. John Sutherland states that it may affect 14% of the overall population, 70% of the military and 34% of those with a substance abuse disorder. PTSD will join the list of indications approved for the use of cannabis in Minnesota this July.

Marv Segal has again come up with an excellent Luminary to recognize, Mark Willenbring, M.D. I think two of the important takeaways from this issue are, don’t use opioids for chronic pain and lower the number of addicts by prevention and intervention, not just concentrating on closing down the sources. Proceed and discover your own takeaways.

March/April 2017

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President’s Message

Challenging Conversations MATTHEW A. HUNT, M.D.

TCMS WORKS IN MANY ARENAS TO ADVANCE OUR GOALS. Our three main external goals are focused on community and public health, health policy, and advocacy for our physicians and their well-being. Examples include our work with Honoring Choices, the Physician Advocacy Network and e-cigarettes, and our work with healthy communities, including prediabetes. It was wonderful to see these on display at our annual meeting in January. However, to achieve our goals in these areas, TCMS can’t do this work alone and must partner with others. Fortunately, our executive staff has done great work over the past several years transforming our organization into one that is able to develop the relationships needed to make these efforts successful. We have made this happen with hospital and healthcare system support for Honoring Choices, and lobbying efforts to create legislative support to make it successful statewide. It has required leadership from people like TCMS Past President Ken Kephart, M.D. and Sue Schettle, CEO, and legislative champions Rep. Joe Shomacker and Sen. Kathy Sheran. Also, BCBS Center for Prevention has supported our tobacco advocacy work. We have chosen partners who believe in our goals and make advances that seemed impossible when we first set out. I am proud to serve an organization that can make such positive changes for our patients and members.

Sometimes, we have to work with others towards goals that challenge everyone involved. This month’s issue highlights one of these areas: opioids. Patients expect doctors to treat their pain, and when I was in medical school, the “5th Vital Sign” was emphasized. We now realize that the consequences for these treatments are much higher than initially thought. We owe it to our patients to explain these issues in ways they can understand. Crucial Conversations1 is a book that provides tools to have these conversations when the stakes are high, opinions differ, and emotions get the better of us. Using these tools, we can have safe, effective conversations where we focus on the shared goals that we and our patients identify. I know it has helped me get through some of these difficult conversations.

Finally, I want to thank Carolyn McClain for her positive, enthusiastic leadership over the past year. I have learned a lot from her, and hope to carry her energy forward into the future.

1) Patterson, Kerry, Joseph Grenny, Ron McMillan, and Al Switzler. Crucial Conversations: Tools for Talking When Stakes Are High. New York: McGraw-Hill, 2012.

Carolyn McClain, M.D. receives the outgoing Chair's Award from Matthew Hunt, M.D.

CORRECTION:

Apologies to Kristin Dillon, Ph.D., co-author of article “Causes and Potential Solutions to Our Crisis in Care for Psychiatric Patients,” Jan/Feb 2017, pg 6, for the incorrect spelling of her name.

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

A Year in Review On January 17th, TCMS leadership, board and committee members gathered to celebrate our work accomplished in 2016. Highlighted below are a few of these achievements. More good news is that TCMS had the most successful grant year in the organization’s history.

Honoring Choices • •

for information and training about Advance Care Planning.

Held 6 Advance Care Planning Facilitator Training Classes, orientation for all 4th year medical students at U of M, 10 informational sessions for health care professionals and mentoring of medical students and Minnesota’s leading resource

MetroDoctors • •

Primary TCMS communication tool, it features interviews with colleague leaders in health care and topics of interest to all physicians.

Celebrates Luminaries of Twin Cities Medicine.

January/February 2017

DNP students.

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Mental Health Insights

Physician Advocacy Network •

Educated over 600 health care providers and students

•

Advanced tobacco control policies

about emerging

tobacco products. in local communities.

The Convenings • •

Provided a safe environment to start thinking about end-of-life wishes.

A series of 6 free community events in 2016-17 were held in Ely, Luverne, Anoka, St. Cloud, Northfield and Owatonna/Faribault.

Twin Cities Medical Society Foundation • •

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Provided $23,000 in grants to community organizations.

Awarded your colleagues for exemplary service: Charles Bolles Bolles-Rogers Award: Patrick J. Flynn, M.D.; Shotwell Award: Patricia F. Walker, M.D.; First a Physician Award: Kenneth N. Kephart, M.D.

March/April 2017

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Addiction

Physicians Serving Physicians

I

t is estimated that there are currently two million people in the United States with Opioid Use Disorder (OUD). Every year 1% of those affected will have a fatal overdose. In Minnesota, there were 338 overdose deaths in 2015.

According to the Centers for Disease Control and Prevention, this number has risen every year since 1999.

Opioid addiction is so prevalent that most of us personally know someone — a family member, friend, or neighbor that is suffering.

While it would be nice to think that the physicians we trust with our care are somehow immune to addiction, they are not. Subjected to long hours and intense stress on the job, drugs can become a crutch to help relieve stress or pain. Estimates suggest that approximately 15% of physicians will develop a substance use disorder at some point in their careers.

For alcohol and illegal drugs like cocaine this is similar to rates seen in the general population. However, the rates of abuse of opioids are actually higher, probably because of easier access to these drugs.

With a growing shortage of doctors, helping to keep the ones we have in practice is important. Rehabilitation of doctors in Minnesota begins with resources like Physicians Serving Physicians (PSP).

PSP was founded in 1981 by Dr. Robert (Bud) Premer who, at the time, was chief of orthopedic surgery at the

By Annie Burton, M.D.

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March/April 2017

VA Hospital and an associate professor at the University of Minnesota Medical School. “There was very little knowledge of addiction and interventions at the time,” he said. He secured a donation of $5,000 from the Hennepin County Medical Society and PSP was born with the core mission to provide help to physicians, medical students, and family members affected by addiction.

The first organizational meeting was in his office at the VA Hospital, “We had about 12 members in the first year,” he said. It rapidly grew into a small group of physicians in recovery and the meetings were moved to a little room at St. Mary’s Hospital, now Fairview Riverside in Minneapolis. When asked about those early meetings he states, “We formalized the intervention process, had regular meetings, and learned as we went along.”

Over the years PSP has grown into a large voluntary network of physicians

who get together monthly to share stories, inspiration, support, and guidance.

PSP is staffed by Diane Naas as the executive director, a licensed alcohol and drug counselor. Some of the services PSP offers include help with identification of persons currently suffering from chemical dependency or mental health illness, education about the illness, and leading interventions when indicated. In addition, counseling and education for families, coworkers and other concerned parties is provided. Since its inception PSP has helped more than 880 physicians and their families.

PSP is not affiliated with the Minnesota Board of Medical Practice (BMP) or the Minnesota Health Professionals Services Program (HPSP). They seek to maintain the confidentiality of those seeking assistance to the extent possible.

The organization is 100% funded by donors like the Minnesota Medical Insurance Corporation (MMIC), hospitals, medical societies, physicians, and other donors.

There are no fees for membership.

Referring a colleague, friend, or oneself, begins with a simple phone call. However, it is not always easy. There is a natural reluctance to approach a co-worker or friend suspected of drug addiction.

The impaired physician is often fearful of seeking help themselves because of discipline by law enforcement, punitive

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Addiction Physicians Serving Physicians (Continued from page 6)

actions by the state licensing boards, and the potential for loss of professional practice. Pausing one’s career to seek treatment can seem daunting.

The good news is, when it comes to addiction, physicians actually make great patients. After seeking help they succeed at rates much higher than the general population and have a markedly lower risk of relapse. Studies show a greater than 80% recovery rate after five years(1) when they complete treatment and receive ongoing support from groups like PSP. Most physicians remain licensed and employed five years after treatment.

There are several theories as to why this patient population is so successful.

Physicians typically start using drugs

later in life, not in their teenage years.

Having spent long hours and large sums of money on their careers, they have a lot to lose. In addition, they are encouraged to participate in ongoing monitoring by agencies like HPSP in order to continue to practice. These programs are very effective. In fact, impaired physicians that don’t participate in monitoring programs and recovery groups like PSP have a relapse rate closer to that of the general population.

In order to effectively handle the opioid epidemic that is currently sweeping the nation we, as a society, need to shift from viewing addiction as a moral failure to treating it as the chronic progressive illness that it is.

Physicians in recovery possess qualities that are highly sought after in a caregiver — humility, empathy, respect, and

patience. With resources like PSP, recovering physicians can effectively and safely return to productive practice. www.pspmn.com.

Annie Burton, M.D. is a physician at Fairview who specializes in treating patients with chronic pain and addiction. She is a graduate of the University of MN Medical School where she also completed her residency in Anesthesiology and fellowship in Pain Management. She is currently serving on the board of Physicians Serving Physicians as Chairperson.

References: 1.

DuPont, Robert L., et al “How are addicted physicians treated? A national survey of physician health programs.” Journal of Substance Abuse Treatment 37 (2009), 1-7.

Cloud Chasing and Blueberry Delight: The Changing World of Youth Tobacco Use The Twin Cities Medical Society’s Physician Advocacy Network and the Minnesota Department of Health invite you to view a free webinar discussing the rapidly evolving trends in youth tobacco use and recommendations on how to address these issues in your practice.

Now available online at

www.panmn.org

This activity has been approved for AMA PRA Category 1 Credit™.

This webinar is supported by the Minnesota Medical Association.

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Who Needs the Health Professionals Services Program?

The first time I spoke to my HPSP case manager, she said, “Listen Mary, after the first 12 months this will be easier.” By “this,” she meant being in HPSP. I didn’t believe her, and I told her so (and a few other things as well). But now after 12 months, I know I never would have survived as a sober person without the recovery structure of HPSP. Mary’s feelings when she first enrolled in the Health Professionals Services Program (HPSP) are not unusual. Fortunately, her feelings about HPSP a year later are also not unusual. The accountability of HPSP reinforces sobriety, especially those first critical months when the brain is learning new pathways away from compulsive thinking and behavior toward health and wellbeing. Even though Mary’s addiction did not directly impact her practice, she learned from her treatment counselors that addiction is a chronic progressive illness if left untreated. She previously had a desire to be free of her addiction as evidenced by her three attempts at cutting down on her alcohol use and there were times when she was able to abstain from alcohol use for a couple of months. However, she learned that sincere intentions were not enough. Each time she returned to alcohol use, her drinking increased. Why? It wasn’t because Mary was morally weak or lacked willpower. Addiction specialists tell us that drugs and alcohol work on the brain’s reward pathways and the addicted brain is a “high-jacked brain” — a vicious, compulsive cycle.

By Monica Feider, MSW, LICSW

MetroDoctors

How HPSP Got Started

Legislation for HPSP was first proposed by five health licensing boards in 1993 with the support of their state professional associations. The boards determined they needed a more effective way to address practitioners with potentially impairing illnesses and reduce the possibility for patient harm. The program was created the following year to serve the boards of nursing, medical practice, dentistry, pharmacy, and podiatric medicine. The program was expanded in 2000 to cover all regulated health occupations. To date, HPSP has enrolled over 6,000 participants, including almost 900 physicians.

How Does HPSP Work?

Board action is often seen as punitive; therefore, licensed practitioners tend to hide the symptoms of their substance, psychiatric, or other medical condition that may cause impairment. Employers and coworkers are often reluctant to file a formal complaint when they suspect a colleague might be in trouble with an illness. HPSP offers an incentive for licensed practitioners to voluntarily get help without board involvement as long as they comply with monitoring requirements. Anyone who is worried about a health care provider’s ability to practice safely, including work supervisors and colleagues, or treatment providers such as a therapist or counselor can send a confidential report to HPSP. The identified practitioner is given an opportunity to confidentially enroll in the program and get appropriate care. The practitioner’s regulatory board will not be informed if they meet program eligibility requirements and cooperate. HPSP’s

The Journal of the Twin Cities Medical Society

reporting obligations are reviewed with the practitioner before identifying information is gathered.

HPSP is not a treatment program.

Rather, HPSP protects the public and helps practitioners by assessing symptoms, developing monitoring contracts, coordinating and facilitating treatment, communicating with treatment providers and work sites, and providing ongoing monitoring.

What are the Benefits of HPSP?

Multiple studies have shown that health professionals who participate in a monitoring program like HPSP have better outcomes and can ultimately preserve their careers. Favorable five-year outcomes are seen in 75% of physicians in monitoring programs in contrast to 40%-60% relapse rates in the general population. Health care employers are able to retain a safe and competent workforce and rural communities can keep their hometown pharmacy, ambulance service, dental providers and other medical clinics in business.

Licensing boards are able to lower their legal costs by referring licensees to the program for voluntary monitoring.

Board members and staff can use the expertise of HPSP to process complaints about drugs, alcohol, mental health, and other conditions.

How do Physicians Compare to Other Professions?

Decades of research consistently show health professionals meet diagnostic criteria for substance use disorders at the same rates as the general population. Research (Continued on page 10)

March/April 2017

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Addiction Health Professionals Services Program (Continued from page 9)

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has also shown that physicians who practice emergency medicine, psychiatry and anesthesiology may be at a higher risk for developing substance use disorders.

In Minnesota, physicians tend to selfrefer to HPSP and successfully complete monitoring at a higher rate than most other health professionals.

How to Get Help?

How to Report?

If you are struggling with substances or mental health, we strongly encourage you to call us at (651) 642-0487. We’ll explain more about how HPSP can help. If you are concerned about a colleague, you may also call, and we will ask you to complete a third party referral form, which can be found on our website. All third party referrals are confidential and subject to immunity if made in good faith.

Monica Feider, MSW, LICSW, is Program Manager, Health Professionals Services Program. She can reached at: (612) 317-3060, or Monica.Feider@state.mn.us.

Resources: • HPSP: Call (651) 642-0487 to talk to a case manager. A brief informational video about HPSP can be found at: http://mn.gov/boards/ hpsp/.

• Physicians Serving Physicians (PSP) offers a range of services to physicians, including monthly support group meetings. For more information, call (952) 920-5582 or go to: http://psp-mn.com/.

• The National Institute of Drug Abuse (NIDA) has excellent information about the disease of addiction: https://www.drugabuse.gov/ publications/drugfacts/understanding-druguse-addiction.

• The Substance Abuse and Mental Health Services Administration (SAMHSA) provides information about substance and psychiatric disorders as well as resources for treatment: http://www.samhsa.gov/.

• Federation of State Physician Health Programs has information on programs similar to HPSP throughout the United States: http://www. fsphp.org/state-programs.

• The National Institute of Mental Health provides information about psychiatric disorders, treatments and other interesting topics: https://www.nimh.nih.gov/index.shtml.

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Colleague Interview: A Conversation with Charles Reznikoff, M.D.

C

harles P. Reznikoff, M.D. is an Addiction Medicine specialist at Hennepin County Medical Center. He earned his medical degree from the University of Wisconsin; completed an Internal Medicine residency, followed by a chief residency at Hennepin County Medical Center, and then completed an Addiction Medicine fellowship at the University of Minnesota. Dr. Reznikoff is an Assistant Professor of Medicine at the University of Minnesota and is Board Certified in Internal Medicine and Addiction Medicine.

Since the late 90s when doctors were told that opiates were safe and effective for chronic pain management, there has been a dramatic increase in opioid dependence, treatment admissions and overdose deaths. Do you think this approach was misguided? Would you counsel physicians to avoid opioids for chronic pain in the future and not start patients down this road?

In both the CDC 2016 opioid guideline and the ICSI 2016 pain guideline, practitioners are clearly advised that until we know more, opioids should not be started for chronic pain, and for those in chronic pain who are already on opioids, the patient should be counseled about tapering. Many times in medicine we make well meaning but misguided therapeutic interventions based on incomplete data (hormone replacement for menopause in women for example, and proton pump inhibitor antacids widely used in all people for another). These are often well intentioned but are sometimes profit motivated on the part of big pharma. Therefore, yes, misguided at best and profiteering (cynically) at worst.

What is your treatment approach to a patient with chronic pain?

Treatment of chronic pain requires a multidisciplinary team — mental health, pain specialty, primary care, physical

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therapy, addiction medicine and, most of all, full patient participation in each of these areas. Chronic pain treatment requires long-term cautious care. Note that current recommendations are against using opioids for chronic pain. That may change in the future.

Comment on the validity and/or value of the Visual Analogue Scale.

The 1-10 numerical pain scale was validated to be used in a patient for a given acute pain over the course of that acute pain’s treatment. The numerical answer, “I have 7 out of 10 pain,” does not in itself have any significance. “My pain was a 7 out of 10 and now after the treatment you gave me one hour later it is 4 out of 10.” That has significance. The numerical scale was not validated in addiction or in mental health. If used solely to manage response to treatment over the course of a single pain event, the 1-10 pain scale has merit. Aside from that it is not valid and potentially harmful to the patient.

(Continued on page 13)

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The road to life-changing pain management treatments Prescription opiate misuse and opiate dependence have increased dramatically since 1999.

Clinicians at HealthPartners and researchers at HealthPartners Institute are partnering closely to improve pain management and reduce opiate use through patient-centered care at all levels.

HealthPartners Institute is one of the largest medical research and education centers in the Midwest.

As part of an integrated health care organization that includes hospitals, clinics and a health plan, our teams are helping transform health care across the nation.

HEALTHPARTNERS NEUROSCIENCE CENTER Opens April 2017 Alfred Clavel Jr., MD Department Chair HealthPartners Pain Management Anne Pylkas, MD Addiction Medicine HealthPartners Pain Management

450+ ACTIVE RESEARCH STUDIES EACH YEAR

Colleague Interview (Continued from page 11)

What options do you employ when your patient is not cooperative or compliant?

Careful informed consent. Professionalism. Never exceeding or breeching one’s personal sense of medical professionalism and medical decision making. Debriefing with colleagues is critical in these instances. An experienced colleague can help navigate these difficult situations.

Many patients on opioids for chronic pain management maintain that they are effective and help them function; however, disability claims from chronic pain conditions such as joint and back pain have continued to increase despite the use of these medications. Do you think opioids are an effective way of getting patients re-engaged in their lives?

What would you tell physicians and patients when the medicines seem to provide initial improvement and relief?

Opioids alone are not a good way to get people to reengage in their life, and, in fact, in some vulnerable patients, opioids will actively interfere with and undermine their attempts to reengage in life because opioids are so addicting.

What strategies have you found effective in transitioning a patient from acute pain medication use to a chronic pain medication use situation? Please offer some suggested ways to open a conversation about what can be a tricky/hot-button topic.

The key point here is twofold. First, differentiate chronic pain from chronic opioid use. They are different. What I suspect this scenario refers to is chronic opioid use, not chronic pain. When a patient is given opioids for an acute event, over time it can become chronic. Then patients can start to develop problems with the opioids, thus the concern. Chronic pain begins technically at 90 days or three months; however chronic opioid use develops much sooner. The state measured this and found that opioid use has already developed chronicity at 45 days, so even that is too late. Basically, physicians should start intervening in the opioid prescription immediately, at the latest at the first refill. Of people taking opioids for pain, 10% get addicted and 30% misuse opioids, so we really cannot be careful enough or act soon enough.

If you wait for the 89th day and say “tomorrow it will be chronic pain!” it is way, way too late.

Please outline your treatment approach to a patient severely addicted to opioids.

There are three FDA approved and evidence-based treatments for opioid addiction: intramuscular naltrexone, sublingual buprenorphine and oral liquid methadone in a clinic. The first is the new kid on the block and we know it helps but we are not sure if there is mortality benefit. Buprenorphine and methadone are well established to save lives, improve function, reduce HIV transmission, reduce incarceration and improve pregnancy outcomes. In other words not offering one of these treatments to a patient who is addicted is, in my opinion, malpractice that jeopardizes the patient’s life. Also, opioid addicts in an overdose situation should be offered injectable or nasal naloxone which is the opioid overdose antidote and may save their life.

What are your thoughts on the efficacy and the clinical value of an office-based buprenorphine program, and the potential downsides of such a program?

This is a life-saving treatment that I believe every doctor in the state who prescribes opioids should strongly consider getting a license and, if not, have a community referral resource. The downside right now is that because so few doctors are reluctant to take on a buprenorphine license, if you get a license you may get a call asking for help every day. I would suggest to doctors starting out with a license to use it on their own patients in whom they themselves caused an iatrogenic addiction. The other downside is that providers need to know when a patient has too severe an addiction, or mental illness, to be managed by primary care. Administering buprenorphine is one of the most wonderful and fulfilling parts of my job. I would highly recommend all community primary care physicians get the license. It is worth it.

Should this be available in a general primary care setting?

Yes. Please note that there will hopefully be a new system in the state to support community buprenorphine providers with expertise consultation if they need it.

When psychiatry is the major current presenting problem, how does one manage detoxification in a psychiatric setting?

It is more complicated and challenging to detox a patient who is in a mental health crisis. They may need to be in a controlled setting such as a detox center or inpatient psych unit. The physician may want to prioritize mental health treatment and detox, or each disease may undermine the other.

(Continued on page 14) MetroDoctors

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Addiction Colleague Interview (Continued from page 13)

There has been abundant media coverage about opiate addiction, but very little about benzodiazepines (benzo) addiction. A couple of questions concerning this class of pharmaceutical agents: a.

How prevalent is the problem?

Benzo abuse or misuse is common. Adverse effect of combined benzos and opioids is a HUGE problem — the highest risk of overdose death is when someone is on both benzos and opioids together. But benzo addiction per se, is not that common. Benzos are by far most problematic as a cofactor in otherwise at-risk patients — it complicates their care and increases their risk. b. How would you rate its comparison to opioids?

Much safer and less likely to cause addiction; but in combination with the opioids, it is the worst case scenario. c. Are there some national/specialty specific guidelines regarding prescribing these medications, especially those like Xanax.

No, sadly. There is inadequate information on safely prescribing benzos. We can now say that it is clearly UNSAFE to mix benzos and opioids and the risk is DEATH. We know that benzos cause falls and motor vehicle accidents and are particularly dangerous in older folks, but we don’t know much more than that.

In regard to narcotic management (this also applies to sedatives/hypnotics like benzodiazepine, some state medical licensing boards have required all licensed physicians in that respective state to undergo education in pain management in regard to narcotic prescribing. What is your opinion on whether this is something that should be considered here in Minnesota, along with education on sedative/hypnotic management?

As I think you know, technically “narcotic” means opioids, and not sedative hypnotics. There is currently language being developed to mandate physician prescriber education in the state for all people with a DEA prescribing license. I am not for mandating the content of physician education but something has to change.

The public has a high degree of urgency and the politicians will respond unless we change ourselves, which we have not adequately done. So while I do not support it, I fully understand the urgency.

One of the unintended consequences I want to avoid in mandatory CME is ... who produces the content? If that is not carefully designed, then we may find that big pharma with deep pockets provides this content for our states’ medical providers, and in doing so gives us slanted information. For physicians seeking high-quality, unbiased, physician education on pain and addiction, I suggest checking out mnmed.org/painseries.

Recovery for

everyone

in every way.

OUTPATIENT | SHORT TERM | LONG TERM | TEEN | PREVENTION

Freedom from addiction starts here. www.mntc.org

Referrals welcome. Call 612-FREEDOM today, for more information.

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MN Law Soon to Require Prescribers to Register for Access to the Minnesota Prescription Monitoring Program Database

A

bill passed during the 2016 Minnesota legislative session will require all Minnesota licensed prescribers who hold a valid DEA prescriber registration and who practice in this state, to register for and maintain an account with the Minnesota Prescription Monitoring Program (PMP). Such prescribers must register for an account no later than July 1, 2017.

Minnesota is one of 49 states that currently has an operational PMP. The Minnesota PMP, which is administered by the Minnesota Board of Pharmacy, has been operational since January 2010 and continues to collect an average of eightmillion controlled substance (Schedules II-V), gabapentin and butalbital prescription records annually. In 2016 alone, more than 1.2M queries of patient profiles were requested by more than 16,000 prescribers who had been granted direct access to the PMP database.

Prescribers who are authorized to prescribe controlled substances may apply for access to the database by completing an online access request form. Once the information has been submitted electronically, the credentials provided will be verified and notifications regarding the status of the account request will be sent via email, normally within 15 minutes of application. Access Request Forms can be found on the MN PMP website at www.pmp. pharmacy.state.mn.us — on the “PMP User Registration and Resources” page.

Registration and Access are Free!

Prescribers may access the PMP database 24 hours a day, seven days a week.

By Cody Wiberg, PharmD, MS, RPh and Barbara A. Carter

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Prescribers themselves or their employers may decide how often and when they will request patient profiles. Some may decide to do so for all patients for whom the prescribing of a controlled substance is being considered. Others may do so only when they suspect potential abuse, misuse or diversion. The reports can be used to determine appropriate medical treatment such as referral to a pain-management specialist as well as to identify “doctor-shopping” behaviors. The PMP encourages prescribers to assist individuals tentatively identified as having an issue of concern regarding controlled substances in finding the help they need. Recent improvements to the PMP website include a resource section for prescribers with links to prescribing and screening tools as well as treatment resources.

In addition to checking on a patient’s controlled substance prescription history in the state of Minnesota, an authorized practitioner with an active Minnesota PMP user account has the ability to view their patient’s history in other states.

Through the “Multiple State Query”

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function a prescriber, after selecting from a list of states currently participating in an interstate data exchange, can locate additional patient information. Minnesota is now actively participating with 29 states with additional states coming on board in the near future.

A prescriber with an active PMP account may also use the system to access a report of the controlled substance prescriptions dispensed using their DEA registration number. This functionality enables the prescriber to monitor use of their DEA registration number and to potentially detect fraudulent use.

Prescribers must respect confidentiality, and may only access data on those patients for whom they are directly providing care, in accordance with Minnesota Statutes Section 152.126. Patient profile reports from the Minnesota PMP database are designated as private data and can be used to supplement an evaluation of a patient, confirm a patient’s drug history, or document compliance with a therapeutic (Continued on page 17)

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AN INTEGRATED APPROACH TO TREATING OBESITY

2017 Bariatric Education Days Presented by the University of Minnesota Department of Surgery Learn about innovations in treating obesity Providing excellent care means knowing as much as possible about available treatment options.

Learn about advances in the care of bariatric patients in this one-anda-half-day conference designed exclusively for health care practitioners.

Sessions include: • Innovative obesity research/medications and obesity treatment in adolescents and adults • Bridging the gap between medical and surgical weight management • Medical and surgical management of obesity in adolescents • Treatment of comorbidities in the obese patient • Surgical video case presentations

For more information about the program or to register, visit mhealth.org/bariatricdays The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©2017 University of Minnesota Physicians and University of Minnesota Medical Center.

Bariatric Education Days will be held May 25 and 26, 2017 at the Radisson Blu Mall of America in Bloomington, MN. This conference has been approved for AMA PRA Category 1 Credits™ and ANCC Credits. Minnesota Board of Psychology approval pending.

MN Prescription Monitoring Program Database (Continued from page 15)

regimen. However, the Minnesota Board of Pharmacy cannot guarantee that any patient profile is accurate or complete.

Dispensers have an obligation to accurately report all controlled substance prescriptions that they have dispensed to the PMP database. However, they don’t always do so — despite the efforts of the Board’s PMP staff to monitor the reporting of prescriptions and to work with dispensers to correct inaccurate or incomplete data.

For information regarding the requirement to register for a PMP account, please contact the appropriate health licensing board. The Board of Pharmacy has worked with the boards that license prescribers to integrate registration into online renewal processes. However, prescribers can also register on the PMP website, as mentioned above.

For more information about MN PMP or to inquire about the registration process or the status of your account please contact the PMP office via email at minnesota.pmp@state.mn.us or at (651) 2012836.

Cody Wiberg, Executive Director of the Minnesota Board of Pharmacy, received a Doctor of Pharmacy from the University of Minnesota. He has worked as a clinical pharmacist, community pharmacist and nursing home consultant. From 1999, until he joined the Board in September of 2005, he was the Pharmacy Program Manager for the Minnesota Department of Human Services. Dr. Wiberg is a Clinical Assistant Professor for the University of Minnesota College of Pharmacy and an Instructor and Course Director for the University of Florida Graduate School. (From which he received a Master of Science in Pharmacy Policy and Outcomes in 2009).

Your Link to Mental Health Resources

Barbara A. Carter currently manages Minnesota’s Prescription Monitoring Program at the Board of Pharmacy. She received her certification in Project Management from the University of Minnesota and her certification in Data Processing & Programming from Hennepin Technical College. Ms. Carter currently serves as the Vice President of the National Association of State Controlled Substance Authority’s (NASCSA) and cochairs their PMP Committee.

2016 Minnesota Statutes 152.126 PRESCRIPTION MONITORING PROGRAM.

Subd. 9. Immunity from liability; no requirement to obtain

information. (a) A pharmacist, prescriber, or other dispenser making a report to the program in good faith under this section is immune from any civil, criminal, or administrative liability, which might otherwise be incurred or imposed as a result of the report, or on the basis that the pharmacist or prescriber did or did not seek or obtain or use information from the program. (b) Nothing in this section shall require a pharmacist, prescriber, or other dispenser to obtain information about a patient from the program, and the pharmacist, prescriber, or other dispenser, if acting in good faith, is immune from any civil, criminal, or administrative liability that might otherwise be incurred or imposed for requesting, receiving, or using information from the program.

Reprinted with permission 2016 by the Revisor of Statutes, State of Minnesota.

Health Initiative Award Winner 2015

Innovation Award Winner 2015

Award Winner 2015 Health Innovation in Patient Care Award Winner 2015

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March/April 2017

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Sponsored Content

A Proactive Approach to the Opiate Prescription Crisis with Compassionate, Patient-Centered Care Contributed by Alfred L. Clavel Jr., M.D. and Beth Averbeck, M.D. The 2011 Institute of Medicine report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research estimated that 100 million Americans have chronic pain.

Over the last 15 years, the primary reliance on and excessive use of opiate medications has created a serious medical crisis. From 1999 to 2013, the use of opiates quadrupled in the United States — without improvements in quality of life, general health measures, disability or pain management. At the same time, rates of prescription opiate overdoses and fatalities have skyrocketed to outnumber deaths by car accidents and gunshot wounds. A smaller but still significant number of deaths from heroin-related overdoses have occurred in which a prescription opiate was the gateway drug to heroin addiction.

The United States, which makes up 5% of the world population, uses 80% of the world’s opiates. Unfortunately, aggressive treatment and compassionate care have not resulted in the kinds of outcomes that patients, clinicians and society expect. The Centers for Disease Control and Prevention (CDC), which call the opiate situation an epidemic, released guidelines in 2016 to promote safe opiate prescribing.

The CDC guidelines were based on a systematic review of the published literature with accumulated non-trial epidemiologic data over the last 20 years. This unique, long-term perspective clearly showed the dangers of excessive, high-dose opiate use.

Addressing this crisis will require considerable effort and commitment across all health-related fields.

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March/April 2017

Establishing Comprehensive Care Through Integrative Programs

Over the last six years, HealthPartners has begun addressing many problems facing pain medicine. It started with the development of a medical spine model to maximize comprehensive, conservative care from the time of presentation to prevent intractable spine-related pain. Chiropractic care has been integrated into some primary care clinics to facilitate timely referral to complement this approach. This model avoids or limits opiate use early in recovery to prevent dependence. This approach was fortuitous, as recent advances in functional magnetic resonance imaging have shown that neuroplastic changes in the brain can occur as early as four weeks after regular opiate use.

Furthermore, opiate-related hyperalgesia, or increased pain sensitivity, begins after the first opiate dose. Thus, opiate reduction needs to follow tissue healing in severe tissue-damaging injuries and avoided altogether in limited tissue injuries

to prevent prolonged hyperalgesia.

After prolonged exposure to opiates, it can take one or two years for the neuroplastic changes to resolve. In some people, they never do.

An emphasis on return to activity and a partnership with Physician’s Neck and Back was the mainstay of treatment for many spine patients. For patients that did not respond, multidisciplinary pain programs, including health psychology and rehabilitation were emphasized across the HealthPartners system, providing additional resources and a shift toward more holistic, patient-centered care. Important to the success of these programs to address the opiate crisis is embedding addiction services and psychiatry directly into the pain clinic. This revolutionary idea follows our understanding of how pain, mood and opiate dependence are linked. Even in healthy individuals, pain and mood are interdependently linked, partly through endogenous opiate mechanisms.

Integrative, individualized, interdisciplinary care combines the care of a team of health professionals to evaluate and treat the whole patient. This approach can help treat chronic pain and wean patients from opiate medications. Preventing opiate withdrawal is the easy part of opiate reduction. To have long-term success in reducing opiate use, a plan must be designed to directly address the hypersensitivity from opiates themselves. After each dose reduction, opiate-related hyperalgesia can last weeks to months. This means that it takes providers from multiple disciplines addressing factors that contribute to pain

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modulation, pain sensitivity and opiate tolerance while incrementally reducing opiate dosing safely and compassionately.

Tapering schedules often take weeks to months and, on occasion, years in patients without opiate use disorder.

The Riverway Pain Clinic in Anoka, MN is a partnership of HealthPartners and Allina Health designed to meet the needs of communities in which opiaterelated problems and deaths are unusually high. This clinic offers pain and addiction medicine specialists, health psychologists and physical therapists in one practice.

Early outcomes suggest that two-thirds of patients referred to the clinic on chronic opiate medication engage in care, with an average opiate reduction of 47mg morphine milligram equivalents (MME) per day, with improvement in pain and function. Similar programs are being developed at multiple HealthPartners locations to respond to the needs of the community.

The Integrative Treatment of Pain and Addiction

The management of multiple medical problems, complex chronic pain and coexistent opiate use disorder is challenging.

Comprehensive assessment allows quick identification of patient needs and barriers to recovery so they can be addressed directly. This includes monitoring of pain, mood, sleep, stress and functional activity.

Stress and distress such as pain can alter opiate tolerance, reduce opiate effectiveness and contribute to pain escalation.

Failing to recognize this pattern can lead to abandoning the taper schedule or, worse, increasing the dose. For example, caring for patients with alcoholic pancreatitis can be complex. Is their increased pain from a progressive disease, tolerance, addiction, loss of control or increasing stress leading to opiate hypersensitivity and poor pain control? These types of issues require a multidisciplinary assessment and treatment. While there are no easy answers in these cases, we all recognize that the old solution of simply escalating opiates because of increased pain is not safe or recommended. Treatment must be individualized to each patient’s disease status, medical needs and life expectancy. For maximum effectiveness, these programs need to seamlessly flow into the treatment MetroDoctors

of the patient’s medical condition, pain and addiction — in and out of the hospital.

Providing Continuity of Care from Outpatient to Inpatient and Back

One way that HealthPartners is attempting to address this issue is providing preoperative pain consultations to help assess patients with complex medical problems, expected prolonged recovery, current chronic pain or previous poor postoperative pain control. By assessing the patient and developing an integrated pain and recovery plan upfront, we can enhance healing and recovery. Often, patients receive a preoperative hypnosis recording to prepare them for surgery, to improve sleep, to reduce anxiety and to begin rebalancing the autonomic nervous system. Hypnosis has been shown to reduce postoperative pain, nausea and recovery times. These improvements reduce the amount and duration of opiates needed and allow faster tapering.

In the future, these programs may integrate into more holistic programs such as yoga, mindfulness, tai chi and functional rehabilitation.

Moving from Patient Care to Systems Work

In addition to clinical programs to increase multidisciplinary care, HealthPartners has developed systems collaboration and integration across clinics through a common electronic health record, monitoring of pharmacy data and feedback to providers on clinical practice variation. One important finding from feedback was that most patients used a small fraction of the prescribed opiate after surgery. Automatic quantities now pre-populate certain prescriptions to more closely match patient use. Finally, HealthPartners’ support of the recently released Institute for Clinical Systems Improvement Guidelines on Chronic Pain Treatment is an example of bringing the latest information on evidence-based care to health care — to everyone’s benefit.

Redefining the Mission of Pain Medicine — Why Not Prevent Chronic Pain?

or illness. These same factors contribute to the prognosis of chronic disease and a patient’s ability to comply with complex treatment plans. Similarly, patients have risk factors and barriers to healing that, when addressed, improve the likelihood of recovery. Because chronic opiate prescribing patterns are a form of palliative care, developing programs to promote rehabilitation, recovery and healing through better understanding of patient needs is essential.

In summary, pain medicine must redefine its mission and focus on improving patient-centered care at all levels. This includes creating a way to assess patients at the beginning, follow them through treatment and measure outcomes. Improving outcomes will allow us to move away from opiate medications and the palliative approach. The integration of the treatment of pain and addiction is necessary for patients with complex conditions. Programs to improve preoperative assessment and planning help identify factors needed to enhance postoperative healing. Finally, the integration of patient-centered care with evidence-based allopathic and complementary care will create better outcomes for providers, patients, communities and health systems.

Alfred L. Clavel Jr., M.D. is a Neurologist and Pain Specialist and current Department Chair of Pain Management for HealthPartners Inc. He served as Medical Director of the Hennepin County Medical Center Pain Program from 1993 to 2006 and practiced at Fairview-University Pain and Palliative Care Center from 2006 to 2015. Dr. Clavel is an owner of the Minnesota Head and Neck Pain Clinic, St Paul, Minnesota, a unique medical-dental integrated clinic.

Beth Averbeck, M.D. is an executive physician leader with extensive experience in quality improvement, clinical operations, measure development, total-cost-of care, physician development and satisfaction and reducing health disparities. She joined HealthPartners in 1992 as a practicing internist and is now responsible for HealthPartners primary care practice.

Each patient has a unique set of protective factors that can enhance healing, adaptability and recovery from injury, surgery

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Addiction

Should Sugar Be Considered a Dangerous Drug?

Disclosures:

Dr. Lustig has never accepted money from the food industry, and has no disclosures with respect to this article. However, Dr. Lustig has authored three popular books as a public health service: Fat Chance: the hidden truth about sugar; Sugar Has 56 Names: a shopper’s guide; and The Fat Chance Cookbook. He is also President of the non-profit Institute for Responsible Nutrition (USA), and an advisor to Action on Sugar (UK).

Q. Can you name an energy source that is not nutrition, for which there is no biochemical reaction in the human body that requires it, that causes disease when consumed chronically and at high dose, yet we love it anyway — and it’s abused?

A. Alcohol. It’s calories (7 kcal/gm), but it’s not nutrition. There’s no biochemical reaction that requires it. When consumed chronically and in high dose, alcohol is toxic, unrelated to its calories or effects on weight. Not everyone who is exposed gets addicted, but enough do to warrant public health interventions.

Clearly, alcohol is NOT a food — it’s a dangerous drug, because it’s both toxic and abused — and we regulate it by taxation and restriction of access.

Dietary sugar is composed of two molecules: glucose and fructose. Glucose is the energy of life. Glucose is so important that if you don’t consume it, your liver makes it (gluconeogenesis). Conversely fructose, while an energy source, is otherwise vestigial; there is no biochemical reaction that requires it. Yet when consumed chronically

By Robert H. Lustig, M.D., M.S.L.

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and at high dose, fructose is similarly toxic and abused.[1] Not everyone who is exposed gets addicted, but enough do, to warrant a similar discussion.

Toxic

In order to demonstrate toxicity, I must show that fructose (and therefore sugar) is an independent contributor to metabolic disease, unrelated to caloric equivalence or effects on weight, and I must show causation.

Prospective cohort studies. Three recent studies, controlled for calories, adiposity, and time, support added sugar as a cause of type 2 diabetes. First, a prospective cohort analysis found that sugar-sweetened beverage (SSB) consumption increased risk for development of diabetes over a 10-year period. Each SSB consumed increased the hazard risk (HR) ratio by 1.29.[2] A second group performed a meta-analysis of studies isolating consumption of soda (n = 17) and fruit juice (n = 13) separately, controlling for calories and adjusting for adiposity,[3] and showed that both increased the relative risk (RR) ratio for diabetes (1.27, 1.10 respectively) over time. Lastly, our group analyzed NHANES adolescent data between 2005-2012, and showed that added sugar increased prevalence of metabolic syndrome;[4] the 4th and 5th quintiles of sugar consumption exhibited a 9.9-fold increase in prevalence over the 1st quintile.

Econometric analysis. Our group joined three databases: 1) the Food and Agriculture Organization statistics database, which lists by food availability per person by country (2000-2010) and by line item (total calories, fruits excluding wine, meats, oils, cereals, fiber-containing

foods, and sugar/sweeteners); 2) the International Diabetes Federation database listing diabetes prevalence by country; and 3) the World Bank World Development Indicators Database which controlled for the confounders poverty, urbanization, aging, physical activity, and obesity.[5] Only sugar generated a signal. For every 150 calories per day in excess, diabetes prevalence increased 0.1%, but if those 150 calories happened to be a can of soda, diabetes prevalence increased 11-fold, by 1.1%. This study meets the Bradford Hill criteria for “causal medical inference” — the same level of proof we have today for tobacco and lung cancer.

Interventional starch-for-sugar exchange. Our group[6] examined the effects of isocaloric substitution of sugar with starch in 43 children with metabolic syndrome over a 10-day period. We reduced percent calories as dietary sugar from 28% to 10%, keeping calories and weight constant. Every aspect of metabolic

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health improved: diastolic BP reduced by 5 mmHg, triglycerides by 46%, LDL by 0.3 mmol/L, and glucose and insulin area under the curve dropped by 8% and 57%, respectively.

Abused

Fructose directly increases consumption independent of energy need.[7] It appears to be, along with caffeine, the food additive that makes “fast food” addictive.[8] Animal studies. Sucrose infusion directly into the nucleus accumbens reduces dopamine and m-opioid receptors similar to morphine,[9] and establishes hard-wired pathways for craving in these areas that can be identified by fMRI.[10] Indeed, sweetness surpasses cocaine as reward.[11] Animal models of intermittent sugar administration induces behavioral alterations consistent with dependence; i.e. binging, withdrawal, craving, and crosssensitization to other drugs of abuse.[12] Human studies. Fructose and glucose, despite being equally caloric (4.1 kcal/gm), and despite the fact that both molecules have effects on the brain, have two completely different sites of action, and generate two completely separate effects. Jonathan Purnell first explored this dichotomy by infusing each sugar intravenously, and measuring the blood oxygenation level-dependent (BOLD) functional MRI signal in the brain. Glucose lit up the cortical executive control areas, but fructose suppressed the signal coming from those control areas.[13] Katherine Page took this a step further by giving an oral glucose or fructose drink. She saw regional cerebral blood flow (CBF) within the hypothalamus, thalamus, insula, anterior cingulate, and striatum (appetite and reward regions) was reduced after glucose ingestion, whereas fructose ingestion reduced regional CBF in the thalamus, hippocampus, posterior cingulate cortex, fusiform, and visual cortex.[14] Bettina Wölnerhanssen demonstrated lack of satiety or fullness with fructose in comparison to glucose, and fMRI lit up the limbic system (amygdala, hippocampus, orbitofrontal cortex).[15] Finally, Eric Stice examined the effects of fat and sugar both separately and together.[16]

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High-fat milkshakes increased brain activity in sensory areas (caudate, postcentral gyrus, hippocampus, inferior frontal gyrus); in other words, where you experience “mouthfeel.” Conversely, high-sugar milkshakes increased brain activity in gustatory regions (insula, putamen, Rolandic operculum, thalamus), where you experience emotion. Increasing the fat content of the milkshakes did not increase the reward properties of the sugar. In other words, the fat increases the salience of the sugar, but it’s the sugar that drives the reward.

Finally, while sugar does not exhibit classic withdrawal, it does demonstrate what the DSM-V qualifies as “dependence,” that is: 1. Craving or a strong desire to use; 2. Recurrent use resulting in a failure to fulfill major role obligations (work, school, home); 3. Recurrent use in physically hazardous situations (e.g. driving); 4. Use despite social or interpersonal problems caused or exacerbated by use; 5. Taking the substance or engaging in the behavior in larger amounts or over a longer period than intended; 6. Attempts to quit or cut down; 7. Time spent seeking or recovering from use; 8. Interference with life activities; 9. Use despite negative consequences.

Sugar recapitulates all the chronic detrimental effects on health as does alcohol,[1] and is a cause of metabolic syndrome.

Sugar is both toxic and abused, similar to alcohol, and should be also treated as a dangerous drug. Indeed, sugar meets all public health criteria for regulation.[17] And indeed, with the passage of municipal soda taxes in Berkeley, San Francisco, Oakland, Albany, Boulder, Chicago, and Philadelphia, the public is now engaged.

Robert H. Lustig, M.D. is a neuroendocrinologist, with basic and clinical training relative to hypothalamic development, anatomy, and function. He is Professor of Pediatrics in the Division of Endocrinology at University of California, San Francisco, and Director of the Weight Assessment for Teen and Child Health (WATCH) Program

The Journal of the Twin Cities Medical Society

at UCSF. Prior to coming to San Francisco in 2001, he worked at St. Jude Children’s Research Hospital in Memphis, TN. Dr. Lustig can be reached at: rlustig@peds.ucsf. edu, or: (415) 502-8672.

References 1.

Lustig RH. Fructose: it’s alcohol without the “buzz.” Adv. Nutr. 2013;4:226-35.

2.

EPIC-Interact Consortium. Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct. Diabetologia 2013;56(7):1520-30.

3.

Imamura F, O’Connor L YZ, Mursu J, Hayashino Y, Bhupathiraju SN, Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ 2015;351:h3576.

4.

Rodriguez LA, Madsen KA, Cotterman C, Lustig RH. Added sugar intake and metabolic syndrome in US adolescents: cross-sectional analysis of NHANES 2005-2012. Public Health Nutr. 2016;19(13):2424-34.

5.

Basu S, Yoffe P, Hills N, et al. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated crosssectional data. PLoS One 2013;8(2):e57873.

6.

Lustig RH, Mulligan K, Noworolski SM, Lustig RH. Isocaloric fructose restriction and metabolic improvement in children with obesity and metabolic syndrome. Obesity 2016;24:453-60.

7.

Lindqvist A, Baelemans A, Erlanson-Albertsson C. Effects of sucrose, glucose and fructose on peripheral and central appetite signals. Regul.

Pept. 2008;150:26-32.

8.

Garber AK, Lustig RH. Is fast food addictive?

Curr. Drug Abuse Rev. 2011;4:146-62.

9.

Spangler R, Wittkowski KM, Goddard NL, et al.

Opiate-like effects of sugar on gene expression in reward areas of the rat brain. Mol. Brain Res. 2004;124(2):134-42.

10. Pelchat ML, Johnson A, Chan R, et al. Images of desire: food-craving activation during fMRI. Neuroimage 2004;23(4):1486-93.

11. Lenoir M, Serre F, Cantin L, et al. Intense sweetness surpasses cocaine reward. PLoS ONE 2007;2(1):e698.

12. Avena NM, Rada P, Hoebel BG. Evidence for sugar addiction: behavioral and neurochemical effects of intermittent, excessive sugar intake.

Neurosci. Biobehav. Rev. 2008;32(1):20-39.

13. Purnell JQ, Klopfenstein BA, Stevens AA, et al.

Brain functional magnetic resonance imaging response to glucose and fructose infusions in humans. Diab. Obes. Metab. 2011;13(3):22934.

14. Page KA, Chan O, Arora J, et al. Effects of fructose vs glucose on regional cerebral blood flow in brain regions involved with appetite and reward pathways. JAMA 2013;309(1):6370.

15. Wölnerhanssen BK, Meyer-Gerspach AC, Schmidt A, et al. Dissociable Behavioral, Physiological and Neural Effects of Acute Glucose and Fructose Ingestion: A Pilot Study. PLoS One 2015;10(6):e0130280.

16. Stice E, Burger KS, Yokum S. Relative ability of fat and sugar tastes to activate reward, gustatory, and somatosensory regions. Am. J. Clin. Nutr. 2013;98(6):1377-84.

17. Lustig RH, Schmidt LA, Brindis CD. The toxic truth about sugar. Nature 2012;487(5):27-29.

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Help for Adolescents With Co-Occurring Disorders Contributed by Diana Chapa, M.D.

T

he last decade has brought about greater understanding of the treatment needs of adolescents struggling with co-occurring psychiatric and substance use disorders. Although stigma around these disorders persists, these conditions are now more commonly accepted by the public as an illness rather than signs of moral weakness. Psychiatric and substance use disorders are recurrent, neurologically based, serious illnesses that occur across all ages and socioeconomic classes and are illnesses from which individuals with proper treatment can recover.

Substance use in adolescents continues to be a serious public health matter in the United States with 23% of those affected having developed a substance use disorder by the time they are 18 years old.1 According to the National Comorbidity Replication Study-Adolescent Supplement (NCS-A), 78.2% of adolescents reported drinking alcohol and 24.4% reported using drugs by 18 years of age. Among youth with alcohol use disorders, 60% had a comorbid drug use disorder, and 44% of youth first diagnosed with a drug use disorder also had an alcohol use disorder. A significant proportion of these adolescents also have a mental health disorder. As reported in the NCS-A, 32% of those diagnosed with a substance use disorder met criteria for a psychiatric disorder other than substance use disorders, and 24% and 35% of adolescents with a suicide attempt met criteria for an alcohol or a drug use disorder, respectively.1 Youth struggling with deficits in self-regulation from dysfunction in frontal cortex, striatum, and limbic systems are at increased risk of developing substance use and co-occurring disorders,

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as cross-disciplinary research over the last decade has elucidated.2 Adolescents presenting at medical offices and emergency departments with cooccurring substance use and mental health disorders are no longer the exception. Cooccurring disorders, however, present a treatment challenge due to the complex interrelationships between these disorders, and the condition can result in increased severity of symptoms and poor treatment outcomes. Symptoms tend to exacerbate and sustain the conditions, further impairing the individual’s function. Factors often seen in youth with co-occurring disorders, such as family or peer substance use, high family conflict, little parental supervision, or victimization, also lead to poor treatment outcomes for these individuals.3,4,5,6 The increasing prevalence of substance use and the strong association between early substance use and increased risk of substance use disorders support the implementation of interventions during adolescence when they have great potential to make a difference across a person’s

lifespan.7 Moreover, the rapidly developing adolescent brain is highly susceptible to the neurotoxic effects of alcohol and drugs, a factor that invites care providers to be vigilant in the assessment and treatment of adolescents with co-occurring disorders.

As adolescent substance use often starts in middle school, pediatricians and primary care providers can play an especially important role in helping identify adolescents at risk. Checkups and well-child appointments with late elementary school-aged patients and their parents can be well suited for anticipatory or guidance conversations on substance use and mental health issues.

The conversations that have been found to be helpful include those where providers refer patient and parents to educational resources, provide brief advice, express concern and the need for change, validate positive behaviors, and schedule follow-up appointments for re-evaluation.

The Screening to Brief Intervention tool (S2BI) has been shown to be highly effective in identifying adolescents at risk for substance abuse as well as in differentiating the severity of illness.8 The S2BI is an eight question screen that assesses for use of eight substances in the past year. The S2BI can be administered quickly and also has information as to when a referral for specialty care should be made, making it a helpful tool to use in primary care settings. The Pediatric Symptom Checklist screen is designed to aid in the identification of cognitive and emotional problems in children, allowing for interventions to be initiated as early as possible. Easily administered in primary care settings, the screen is available at the American Academy of Pediatrics website Bright Futures (brightfutures.aap.org).

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People with co-occurring disorders may seek primary care services before behavioral health services for multiple reasons, one of which is ease of access. Family physicians are also well positioned to recognize substance use in their patients and to take steps to address the issue before it escalates.9 In its May 2015 Adolescent Screening, Brief Intervention, and Referral to Treatment toolkit for providers, the American Academy of Pediatrics advocated for screening of alcohol, marijuana, and other drug use at each patient’s annual well visit, along with screening for injuries and other indications of high-risk behaviors.

The academy’s position reflects a broader health care initiative to move from siloed to integrative care. Research into therapies for co-occurring mental health and substance use disorders indicates that treating each in isolation is not sufficient.10 As supported by the research of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), people with co-occurring disorders are best served through integrated treatment where practitioners along with a multidisciplinary team can concurrently address mental and substance use disorders, an approach that can often lower costs while creating better outcomes. SAMHSA recognizes the following evidence-based interventions: individual and group cognitive behavioral therapy, motivational enhancement therapy, multidimensional family therapy, and functional family therapy. All of these interventions are also components in the evidenced-based practice Integrated Dual Disorders Treatment (IDDT).

Although research into the efficacy of treatment interventions for adolescents is ongoing, results support that adolescents

with co-occurring psychiatric and substance use disorders often benefit from an integrated, multimodal treatment approach that includes psychotherapy, pharmacologic interventions, family involvement, and collaboration with community supports. Program components shown to lead to positive outcomes for youth diagnosed with co-occurring disorders include not only family therapy-based programs but also programs that facilitate engagement, support program completion, provide clinical coaching, and have quality assurance/ outcome measures.11,3,12,13 Psychopharmacological interventions for adolescents with co-occurring disorders include medications with a focus on decreasing substance use and promoting abstinence (naltrexone, acamprosate, Nacetylcysteine), alleviating withdrawal symptoms (buprenorphine, clonidine, antagonist agents), targeting nonsubstance use-related psychiatric disorders (antidepressants, anxiolytics, mood stabilizers).

When providing pharmacological interventions, physicians should closely monitor for possible interactions between illicit substances and prescribed medications and educate the adolescent and their parent/ guardian on the intervention’s risks. The recommended practice at this time is to provide conservative pharmacological interventions for patients with co-occurring disorders, closely evaluate risk and benefit of medications with potential for abuse, and consider prescribing treatments in smaller quantities.

In spite of the challenges co-occurring disorders present to diagnosed individuals and the clinicians providing treatment, the future holds promise. The movement toward integrated care along with increasing access to screening instruments, diagnostics,

At University of Minnesota Health and Fairview Health Services, clinicians employ a multidisciplinary team approach and provide assessment and treatment for adolescent and adult patients with co-occurring disorders. We offer psychiatric, safety, family, substance use, and medical assessments. Disposition planning includes patients and their family/guardian and community providers.

Inpatient programs are located at University of Minnesota Health Riverside campus locations. Outpatient programs are also held at the Riverside campus as well as in surrounding communities. Questions regarding resources and assessment needs can be directed to the Central Intake office at (612) 672-6600.

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and evidenced-based, effective treatment will provide diagnosed adolescents with care that will increase their chance to live the healthy, productive lives they deserve.

Diana Chapa, M.D., serves as the attending physician at the University of Minnesota Medical Center Adolescent Dual Disorder Unit. She is an adjunct clinical professor with the University of Minnesota Child and Adolescent Psychiatry Fellowship Program.

References 1.

Merikangas KR, He JP, Burnstein M, et al.

Lifetime prevalence of mental disorders. In U.S. adolescents: results from the National Comorbidity Survey Replication, Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989.

2.

Kaminer Y, Winters KC, Kelly J. Screening, assessment, and treatment options for youth with substance use disorder. In Kaminer Y., ed.

Youth Substance Abuse and Co-occurring Disorders. Washington, DC: American Psychiatric Publishing;2016.

3.

Tanner-Smith EE, Wilson SJ, Lipsey MW. The comparative effectiveness of out-patient treatment for adolescent substance abuse: A meta-analysis. J of Subst Abuse Treat.

2013;44(2):145-158.

4.

Godley MD, Kahn JH, Dennis ML, Godley SH, Funk RR. The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment for cannabis abuse or dependence. Psych Addict Behav. 2005;19(1):62-70.

5.

Hawkins JD, Catalano JD, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention.

Psychol Bull. 1992;112, 64-105.

6.

Van Ryzin MJ, Fosco GM, Dishion TJ. Family and peer predictors of substance use from early adolescence to early adulthood: an 11 year prospective analysis. Addict Behav. 2012;37, 1314-1324.

7.

Grand BF, Dawson DA. Age of onset of drug use and its association with DSM-IV drug abuse and dependence: results from National Longitudinal Alcohol Epidemiologic Survey. J of Subst Abuse. 1998;10(2):163-173.

8.

Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr. 2014;168(9):822-828.

9.

Griswold, K, et al. Adolescent Substance Use and Abuse: Recognition and Management. Am Fam Physician. 2008, Feb 1;77(3):331-336.

10. Geller, B., et al. Double-blind and placebo controlled study of lithium for adolescent bipolar disorders with secondary substance dependency. J Am Acad Child Adolesc Psychiatry.

1998;37: 171-178.

11. Dennis M, et al. The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. J Subst Abuse Treat. 2004;27(3): 197-213.

12. Muck R, Zempolich KA, Titus JC, Fishman M, Godley MD, Schwebel R. An overview of the effectiveness of adolescent substance abuse treatment models. Youth Soc. 2001;33(2): 143168.

13. Lipsey M. The primary factors that characterize effective interventions with juvenile offenders: A meta-analytic overview. Vict Offender.

2009;4(2):124-147.

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Long-Term Risk with Cannabinoid Therapies: Considering Rhetoric, Science and Compassionate Care

C

annabis, commonly referred to in media circles by the slang — marijuana, has been employed as a medicine for thousands of years. Western medical practice included the use of cannabis-based medicine well into the 20th century. Many modern physicians no longer remember that, in 1936, the AMA supported the continued use of cannabis as a medicine in testimony to Congress as the country grappled with the new social and political motives of the day.1 Multiple complex factors led to the declining medical use of cannabis in the U.S. and an increasing public and political perception that cannabis was associated with negative consequences for the individual and society. Medical education patterns changed to reflect this.

The institutional medical memory on cannabis waned over the years. For decades, U.S. medical education has associated recreational cannabis use with various health risks and implicated it as a “gateway” to more lethal illicit drug use.

Political rhetoric mingled freely with empirical evidence. This education fit the societal paradigm. There has been little incentive to pursue conflicting evidence, especially for physicians seeking to do no harm.

Medical education may have avoided the topic, but its relevance to our practice is unavoidable. The endocannabinoid system (ECS) was discovered in the 1990s.2,3,4 Gateway theories of addiction have been eroded by modern data.5,6 There is a growing recognition that controlled doses of cannabinoids can effectively treat some

By Gary Starr, M.D.

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patients where other conventional treatments have been less effective or harmful. Understandably, many physicians find their training an inadequate preparation for forming an objective opinion. Often, physicians find it challenging to differentiate what has been scientifically evaluated from what they “were told.”

Compassionately treating our patients often requires that we offer well-informed opinions including risk/benefit analyses for patients. This requires an accurate understanding of any likely risks rather than a “common knowledge” formed by conventional wisdom or decades of politically skewed education. Generally, physicians understand that cannabis is relatively safe acutely and does not directly result in death or respiratory compromise. Neutrally discussing the long-term risks and benefits of cannabis is a more complex endeavor.

Any discussion about long-term risk with cannabis use must be contextual. Risk associated with controlled-dose cannabinoids intended to treat symptoms cannot be equated to uncontrolled recreational use intended for pleasure. Studies assessing long-term risk have largely focused on uncontrolled recreational use.

Long-term risks associated with cannabis use are based largely on observational data. While various potential harms associated with cannabis use have been suggested over time, the following associations have supporting data: Regular cannabis use initiated in adolescence may be associated with a small increased risk of schizoaffective disorders later in life.7,8 This susceptibility has not been found in users who began regularly smoking

cannabis as adults. It is not entirely clear whether cannabis use increases the risk or if those persons at greater risk of developing schizoaffective disorders are also more prone to consume cannabis at an early age.

Regular heavy cannabis use initiated in adolescence may also be associated with an increased risk of developing depressive disorders later in adulthood.9,10 Long-term negative effects on cognition and memory have also been associated with heavy regular recreational cannabis use initiated at an early age.11,12 Adolescent patients and patients with a personal or family history of psychosis need to consider these potential increased long-term risks which are difficult to extrapolate to a non-recreational dosing environment.

Unlike cannabis smoked recreationally, many cannabis-based medications have much higher quantities of cannabidiol (CBD) than typical recreationally

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smoked cannabis. CBD may act to protect against some of these negative long-term effects.13 Research does not show a causeeffect relationship between cannabinoids and the above associations. Unfortunately, isolating the effects of cannabis from other drug and alcohol use as well as relevant environmental factors would require prospective study models which are not practical in real human populations.

Physicians often use the terms “addiction” and “dependence” interchangeably, but the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not consider these terms separately now. Instead, the DSM-5 clearly defines Cannabis Use Disorder.14 “Addiction” involves a compulsion to continue a behavior despite the negative consequences, and may or may not involve any “abuse” or physiologic “dependence.”

Research shows that there is a significantly lower prevalence of someone becoming cannabis “dependent” when compared with opioids or alcohol. Cannabis dependence has a profile comparable to caffeine.15 Fortunately for many, there is no “caffeine use disorder” in the DSM-5.

Approximately 9% of those who try recreational cannabis will meet “dependence” criteria at some point.16 Daily recreational cannabis use may have a higher “dependence” risk of 10-20%.17 These rates of developing dependence are less than with any alcohol exposure (15%) and any opioid use (23%).15 Cannabis use disorder requires at least 2 of 12 criteria (DSM-5) be present to make the diagnosis. These can be summarized by the following categories: 1) Impaired Control, 2) Social Impairment, 3) Risky Use, 4) Tolerance or Withdrawal syndromes. A patient taking a controlled recommended dose of cannabinoids for a medical condition and who is not socially impaired or using cannabis hazardously would not necessarily meet the criteria for cannabis use disorder. This could be true even with some expected increased tolerance to cannabinoids over time.

Cannabis and cannabinoid-based medications, like many other therapies physicians commonly employ, have the

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potential to improve patients’ quality of life but carry some associated risks. Cannabinoid treatment benefits and risks need to be considered with the patient’s other medical ailments and other potentially harmful medications. As physicians, we are systemically undereducated on useful information about cannabinoid therapies and overexposed to decades of conflicting non-medical opinion. Our patients will still rely on physician expertise. Providing expert, compassionate care will require that all physicians take the time to re-educate themselves about cannabis in the medical environment.

6.

7.

8.

9.

10.

11.

Gary Starr, M.D. is the Chief Medical Officer for Leafline Labs (Cottage Grove, MN).

He also serves in various leadership roles in the American College of Emergency Physicians. His broad experience guiding medical policy and working with national and state legislators provides a unique perspective on the challenges posed by the intersection of modern medicine, business and politics. Dr. Starr completed his Emergency Medicine residency at The University of Chicago and his Family Medicine Residency at Saint Louis University. He received his medical degree from The University of Cincinnati College of Medicine. He is a veteran of the United States Air Force where he served as a flight surgeon under Special Operations Command.

12.

13.

14.

15.

(Endnotes) 1.

“Statement of Dr. William C. Woodward, Legislative Counsel, American Medical Association.” http://www.druglibrary.org/Schaffer/hemp/ taxact/woodward.htm. Retrieved 2016-12-25.

2.

Matsuda LA, Lolait SJ, Brownstein MJ, Young AC, Bonner TI. Structure of a cannabinoid receptor and functional expression of the cloned cDNA. Nature. 1990;346:561–564.

3.

Devane WA, Hanus L, Breuer A, Pertwee RG, Stevenson LA, Griffin G, Gibson D, Mandelbaum A, Etinger A, Mechoulam R. Isolation and structure of a brain constituent that binds to the cannabinoid receptor. Science.

1992;258:1946–1949.

4.

Mechoulam R, Ben-Shabat S, Hanus L, Ligumsky M, Kaminski NE, Schatz AR, Gopher A, Almog S, Martin BR, Compton DR, Pertwee RG, Griffin G, Bayewitch M, Barg J, Vogel Z. Identification of an endogenous 2-monoglyceride, present in canine gut, that binds to cannabinoid receptors. Biochemical Pharmacology.

1995;50:83–90.

5.

Agrawal A, Neale MC, Prescott CA, Kendler KS. A twin study of early cannabis use and subsequent use and abuse/dependence of other illicit drugs. Psychol Med. 2004;34(7):1227-1237.

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16.

17.

Secades-Villa R, Garcia-Rodríguez O, Jin CJ, Wang S, Blanco C. Probability and predictors of the cannabis gateway effect: a national study.

Int J Drug Policy. 2015;26(2):135-142.

Chadwick, Benjamin; Miller, Michael L; Hurd, Yasmin L (2013). “Cannabis Use during Adolescent Development: Susceptibility to Psychiatric Illness.” Frontiers in Psychiatry (Review). 4: 129.

Gleason KA, Birnbaum SG, Shukla A, Ghose S. Susceptibility of the adolescent brain to cannabinoids: long-term hippocampal effects and relevance to schizophrenia. Transl Psychiatry.

2012;2:e199.

Lev-Ran S, Roerecke M, Le Foll B, et al. (June 2013). “The association between cannabis use and depression: a systematic review and metaanalysis of longitudinal studies.” Psychological Medicine (Review). 44 (24): 1–14.

Blanco C, Hasin DS, Wall MM, et al. Cannabis Use and Risk of Psychiatric Disorders: Prospective Evidence From a US National Longitudinal Study. JAMA Psychiatry. February 2016.

Harefuah. (2013) Dec;152(12):737-41, 751.

[Short-and long-term effects of cannabinoids on memory, cognition and mental illness].

[Article in Hebrew] Sagie S1, Eliasi Y2, Livneh I3, Bart Y2, Monovich E2.

Mclaren, Jennifer. & Mattick, Richard P. & National Drug Strategy (Australia). & Australia. Department of Health and Ageing. Drug Strategy Branch & National Drug and Alcohol Research Centre (Australia). (2007). Cannabis in Australia: use, supply, harms, and responses.

[Canberra]: Australian Govt. Dept. of Health and Ageing, http://www.nationaldrugstrategy. gov.au/internet/drugstrategy/publishing.nsf/ Content/4FDE76ABD582C84ECA257314000B B6EB/$File/mono-57.pdf.

Scuderi, C; Filippis, DD; Iuvone, T; Blasio, A; Steardo, A; Esposito, G (May 2009). “Cannabidiol in medicine: a review of its therapeutic potential in CNS disorders.” Phytotherapy Research: PTR (Review). 23(5): 597–602.

American Psychiatric Association. (2013).

Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

Roques B. Problemes posées par la dangerosité des drogues. Rapport du professeur Bernhard Roques au Secrétaire d’Etat à la Santé. Paris, 1998.

Hall W, Room R, Bondy S. Comparing the health and psychological risks of alcohol, cannabis, nicotine and opiate use. In: Kalant H, Corrigan W, Hall W, Smart R, eds. The health effects of cannabis. Toronto: Addiction Research Foundation, 1999, pp. 477-508.

Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130.

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Co-Occurring Posttraumatic Stress Disorder and Opioid Use Disorder Among Military Personnel Prevalence Posttraumatic Stress Disorder (PTSD) is a serious and debilitating disorder which is estimated to affect as much as 14% of the general population and upwards of 70% of the military population (Solomon, 2001).

One out of eight service members returning from operations in Iraq screened positive for PTSD (Dabbs, Watkins, Fink, Cost, & Millikan, 2014). Substance use disorders are often associated with PTSD. According to Chilcoat & Breslau, 1998, 34% of those individuals receiving substance use treatment also carry a PTSD diagnosis with “hard drugs” such as cocaine and opiates being the drug of choice. From 2001 to 2008, prescription drug abuse rose from 1% to 10%. Even higher rates were revealed from 2007 to 2010 showing a 700% increase in opiate use (Dabbs, Watkins, Fink, Cost & Millikan, 2014). Another long withstanding association with Co-morbid PTSD and Opioid usage is the high suicide risk (Shorter, Hsieh, & Kosten, 2015).

Since active duty military service populations are at a higher risk for PTSD and substance use than the general population, it is important to understand what contributes to these findings. The highest rates of PTSD were associated with service personnel with the least education, of lower rank, in either the army or the marines, and fewer deployments. According to Dabbs et al., 2014, service personnel with one or no deployments had higher odds of opioid use disorder than members who had greater than four. Dabbs and colleagues point out that this is likely explained by what Haley, 1998 describes as the “Healthy-Warrior Effect” in that those personnel with fewer deployments were either removed or found to be mentally and physically unhealthy for additional deployments

By R. John Sutherland, Ph.D.

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(2014). For those individuals who do not deploy again it is essential to begin treatment for both PTSD and Opioid Use Disorder largely because of its profound impact on the survivor’s functionality in society. It is likely that individuals with PTSD use hard core drugs in order to temporarily relieve intrusive thoughts, cognitive distortions and the chronic state of hyperarousal. However, long-term usage impacts brain circuitry and chemistry resulting in a reinforcement of relapse behaviors. According to Shorter, Hsieh, & Kosten (2015), individuals with PTSD are in a constant state of hyperarousal in the amygdala, hippocampus, and medial prefrontal and anterior cingulate cortex which are the same structures that are impacted by opioids. Consequently, it is important that increased awareness is stressed among physicians in order to recommend integrative, evidenced-based treatments such as opioid replacement treatments along with exposure, cognitive behavioral treatments (Johnson et al., 2015).

Treatments (MedicationAssisted Treatment and Exposure Therapy) Outcomes for treatment among co-occurring PTSD and Opioid Use Disorder are poor (Mills, Tesson, Darke, & Shanahan, 2005). However, an integrated model is recommended, not only because this approach is more cost-effective (Peles, Adelson, Seligman, Bloch, & Pothik, 2014), but also likely to eliminate the behaviors of avoidance through negative reinforcement (Foa, 2007).

The first step to consider is referring the patient to an inpatient or outpatient substance use program where the patient can begin a medication-assisted treatment consisting of either methadone or buprenorphine (Suboxone). These medications are used to help suppress withdrawal symptoms

and decrease cravings. Once an individual is stabilized on an opioid replacement regimen, an evidencebased treatment such as prolonged exposure for PTSD (PE) has been found most effective. In patients treated within 10 to 12 weeks with PE, the therapy demonstrates 90% effectiveness (Foa, 2007). According to Foa, once PTSD is treated, medical visits reduced from 8.5 to 3.5 per year resulting in better quality of life and reduced healthcare costs.

Prolonged Exposure for PTSD is a type of therapy that helps decrease distress about a trauma index. The therapy works by helping an individual approach trauma-related thoughts, feelings, and situations that they are avoiding due to the distress they cause.

Repeated exposure to these thoughts, feelings, and situations helps reduce the power they have to cause distress. There are four phases of the treatment including psychoeducation, breathing techniques, real world practice and talking through the trauma.

1. Education: Psychoeducation starts with education about the treatment. The survivor learns about their symptoms as common trauma reactions and PTSD. It also helps them understand the goals of the treatment. This education provides the basis for the next sessions.

2. Breathing: Breathing retraining is a skill that helps a survivor relax. When people become anxious or scared, their breathing often changes. Learning how to control one’s breathing can help in the short-term to manage immediate distress.

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3.

Real world practice: Exposure practice with real-world situations is called in vivo exposure. By approaching situations, a survivor learns that feared situations are objectively safe. In addition, a survivor learns to be confident again because they were able to approach the fear situation without avoiding it.

An example would be a Veteran who avoids driving since he experienced a roadside bomb while deployed. In the same way, a sexual trauma survivor may avoid getting close to others. This type of exposure practice helps your trauma-related distress to lessen over time.

When distress goes down, the survivor gains more control over their life.

4. Talking through the trauma: Talking about the trauma memory over and over again with a trained therapist is called imaginal exposure, which helps the survivor gain more control of their thoughts and feelings about the trauma.

A survivor learns that they do not have to be afraid of their memories.

Another important aspect of any integrative treatment program is case management. Case management includes meeting the basic needs of the survivor, monitoring their progress, service coordination, housing and preventing the survivor from falling through the cracks of the healthcare system (SAMHSA, 2014).

Recommendations PTSD and Opioid Use Disorder are on the rise. Survivors of traumatic events who are diagnosed with PTSD tend to abuse and become dependent on the hardest acting drugs.

It is important to improve awareness of the disorders which includes screening for both diagnoses. Moreover, it is likely that a survivor will be dependent on opioids until their trauma history is resolved since using substances is a good way to avoid what haunts a survivor. Therefore, it is recommended that a survivor receive medical assisted treatment for their opioid use disorder to curb cravings.

Once stabilized, an evidence based PTSD treatment such as Prolonged Exposure for PTSD is recommended in order to help the survivor process their trauma history and begin approaching situations they seek to avoid.

North Memorial Health Care System and oversees all services for mental health and addiction care. Dr. Sutherland is a Licensed Psychologist through the Minnesota Board of Psychology and is Board Certified in Counseling Psychology through the American Board of Professional Psychology. He completed his doctoral internship at the National Center for PTSD, Pacific Island Division and his Post-Doctoral Fellowships at the Michael E. DeBakey VAMC. Dr. Sutherland is certified as a national trainer in Prolonged Exposure for PTSD and is active in the dissemination of evidence based PTSD and Substance Use Disorder treatments. He can be reached at: John.sutherland@northmemorial. com, or (763) 581-2419.

References • Chilcoat, HD, Breslau N: Posttraumatic stress disorder and drug disorders: testing causal pathways. Arch Gen Psychiatry 1998;55(10): 913-7.

• Dabbs, C, Watkins, EY, Fink, DS, Eick-Cost, A, Millikan, AM (2014). Opiate-Related Dependence/Abuse and PTSD Exposure Among the Active-Component U.S. Military, 2001 to 2008.

Military Medicine, 179(8),885-890. doi:10.7205/ milmed-d-14-0001.

• Foa, E, Hembree, E, Rothbaum, B (2007). “Prolonged Exposure Therapy for PTSD: Emotional Process of Traumatic Experiences—Therapist Guide (Treatments That Work).” Oxford University Press.

• Haley, RW: Point: bias from the “healthywarrior effect” and unequal follow-up in three government studies of health effects of the Gulf War. Am J Epidemiol 1998;148(4):31-23.

• Mills, KL, Teesson, M, Ross, J, Darke, S, Shanahan, M (2005). The Costs and Outcomes of Treatment for Opioid Dependence Associated With Posttraumatic Stress Disorder. PS Psychiatric Services, 56(8), 940-945.

• Najavits, LM, Weiss RD, Shaw S. The link between substance abuse and posttraumatic stress disorder in women: A research review.

Am J Addict.1997;6:273–283.

• Peles, E, Adelson, M, Seligman, Z, Bloch, M, Potik, D, Schreiber, S (2014). Psychiatric comorbidity differences between women with history of childhood sexual abuse who are methadone-maintained former opiate addicts and non-addicts. Psychiatry Research, 219(1), 191-197.

• Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. (2014) HHS Publication No. (SMA) 13-4801. Substance Abuse and Mental Health Services Administration. Rockville, MD. • Shorter, D, Hsieh, J, Kosten, TR (2015). Pharmacologic Management of Comorbid PostTraumatic Stress Disorder and Addiction. The American Journal of Addiction, 24,705-712.

• Solomon, Z (2001). The impact of posttraumatic stress disorder in military situations.

Journal of Clinical Psychiatry 2001;62,11-15.

R. John Sutherland, Ph.D., ABBP, is the Director of Mental Health & Addiction Center at

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27

Addiction

Environmental Health — Addicted to Oil? During his 2006 State of the Union address, President George W. Bush stated “We have a serious problem. America is addicted to oil.”1 While we in the medical field might argue this is an incorrect use of the word “addiction,” there is no arguing that the United States is the largest user of oil. In 2011, despite having only 5% of the world’s population, the United States consumed 21% of the world’s oil. Based on 2011-2012 data, the United States imports around 45% of its oil. Seventy percent of this oil is used for transportation.2 Our transportation and food systems are closely linked, and much of our food travels far before it reaches our place.

Americans are traveling more as well, logging over three trillion miles per year

(three times more than in 1971).3 Why is this important? How does it affect our patients? Americans with low-incomes spend about 37% of their income on food and transportation.2 This fact highlights potential consequences our most vulnerable patients might face if we cannot switch to a more sustainable system. As a society, it is estimated the consequences of our oil addiction cost us in excess of one trillion dollars per year.1 So what can we do to kick this habit?

Certainly we can be mindful of our own transportation use. We can focus on choosing locally sourced food and products, and minimize waste. We can encourage our legislators to support the development of wind and solar industries, as well as electric

vehicles. It’s not easy to beat a bad habit, but with effort and determination, we can make strides to become “clean.”

Consider attending the CleanMed 2017 conference. It’s in Minneapolis this year! May 16-18th. cleanmed.org.

References: 1.

Steiner, Richard. “The True Cost of Our Oil Addiction.” The Huffington Post. 1/15/2014. http://www.huffingtonpost.com/richard-steiner/true-cost-of-our-oil-addiction_b_4591323. html.

2.

Breaking America’s Addiction to Oil & Fostering an Age of Energy Dependence: Sustainable America’s Position on Energy. http://www.sustainableamerica.org/downloads/whitepapers/ Energy_White_Paper.pdf.

3.

Dykstra, Peter. “Analysis: Addicted to Oil – The first 10 years.” TheDailyClimate. 1/30/2016. http://www.dailyclimate.org/tdc-newsroom/2016/jan/oil-addiction-george-bushclimate-change-energy.

THE STRENGTH TO HEAL

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Learn the latest treatments and play an important role in the care of Soldiers and their families. As a physician on the U.S. Army Reserve health care team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference.

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©2 20 20 0113. Pai P d forr by by the United Sta ates tes Army. Alll rights res re erved.

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MetroDoctors

The Journal of the Twin Cities Medical Society

Matthew Hunt, M.D. Installed as TCMS President On Tuesday, January 17, Matthew A. Hunt, M.D. was installed as the 2017 President of Twin Cities Medical Society, succeeding Carolyn McClain, M.D. Nearly 80 TCMS physicians and guests, representing TCMS Board, TCMS Foundation Board, and all TCMS committees and work groups participated in the event at Surly Brewing. Dr. Hunt received his medical degree from the University of Louisville School of Medicine, Kentucky; completed a surgery in- Past, Current and Future TCMS Presidents — Drs. Lisa Mattson, Matthew Hunt and Thomas Kottke. ternship, neurosurgery residency, and fellowship in Neurosurgical Oncology (R), 22A, Chair Health & Human Serat Oregon Health & Science University vices Reform Committee, served as the in Portland, OR; and served as a Clinical keynote speaker outlining his legislative Fellow in Neurosurgery at The National priorities and voicing “ardent support” for Hospital for Neurology and Neurosurgery, continuing the work and outreach efforts London, UK. Dr. Hunt is an Associate of Honoring Choices Minnesota.

Professor, Program Director, Neurosurgery Ken Kephart, M.D. was presented Residency Program and Co-Director, Joint (in absentia) with the First a Physician Orthopedic/Neurosurgery Spine FellowAward recognizing a physician for effective ship at the University of Minnesota. leadership, involvement in improving the Minnesota State Rep. Joe Schomacker public health, or policy and/or legislative

advocacy resulting in a positive impact on the practice of medicine or a healthier community. Dr. Kephart fulfills all three criteria. He is a past president of TCMS and currently serves as Medical Director of Honoring Choices Minnesota.

In presenting the outgoing Chair’s Award to Carolyn McClain, M.D., Dr. Hunt reflected that she served as the face of the organization while meeting with Commissioners, the Governor’s office, legislators and others. She also submitted letters to the editor on important topics that were pertinent to physicians in Minnesota.

In addition, her acting skills were put to test by filming a commercial that aired on KARE11 related to The Convenings project, and led a SIMS educational event for her emergency physician colleagues. Dr. McClain has been an outstanding leader representing TCMS. Closing out the evening was comedian, Stevie Ray, who was invited to entertain and highlight his Comedy Cabaret’s 2nd annual “The Life and Death Comedy Show” — a hilariously thought-provoking improv comedy that raises awareness of Advance Care Planning. Part of National Healthcare Decisions Day, this year’s performances will be held April 21 and 22.

Tickets available at www.chanhassentheatres.com.

Representative Joe Schomacker served as the keynote speaker.

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The Journal of the Twin Cities Medical Society

March/April 2017

29

Patricia F. Walker, M.D., DTM&H, FASTMH Receives Shotwell Award The 2016 Shotwell Award was presented to Patricia F. Walker, M.D., DTM&H, FASTMH, at the January 10, 2017 annual meeting of the Abbott Northwestern Medical Staff. Chris J. Johnson, M.D., chair of the Twin Cities Medical Society Foundation presented the award.

The Shotwell Award is presented annually to a person within the state of Minnesota who has made significant contributions in the field of health care.

Dr. Walker is a nationally recognized expert on refugee and immigrant health.

A graduate of Mayo Medical School and Mayo Graduate School of Medicine, she is a Professor, division of Infectious Disease and International Health at the U of M, and an Adjunct Professor in the School of Public Health, Division of Epidemiology and Community Health. For 23

CAREER OPPORTUNITIES

years Dr. Walker served as the medical director of the HealthPartners Center for International Health, a nationally known refugee and immigrant health clinic. She is now pursuing more research and teaching interests as the Associate Program Director for the Global Health Pathway in the Department of Medicine at the University of Minnesota, while also continuing to provide patient care at the Center for International Health.

Dr. Walker is Board Certified in Internal Medicine and holds Certificates of Knowledge in Traveler’s Health, Clinical Tropical Medicine & Traveler’s Health, and a Diploma in Tropical Medicine & Hygiene. On January 1 she was inducted as the 113th President of the American Society of Tropical Medicine and Hygiene as its 6th female President. The organization

Presenting the award to Dr. Patricia Walker, TCMSF Chair Chris Johnson, M.D. (L) and Chase Sovell, M.D. (R), President, Abbott Northwestern Hospital Medical Staff.

See Additional Career Opportunities on page 31.

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The Journal of the Twin Cities Medical Society

March/April 2017

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

MARK L. WILLENBRING, M.D. Clinical capabilities in medicine require dynamic trailblazers to guide their colleagues forward and avoid stagnation. Let’s see how our Luminary has led the way in the important field of Addiction Medicine.

Dr. Mark Willenbring was born on the Minnesota Iron Range and received his undergraduate and M.D. (1974) degrees from our U of M. A rotating internship at Ramsey Hospital was followed by emergency room service at that facility and medical directorships in Minneapolis community clinics. He was keen on mental and behavioral medicine from student days and acted upon that interest via a general psychiatry residency at the University of California Davis, later completing a U of Wisconsin social science research fellowship.

Basic groundwork being accomplished, Mark, father of two and a cycling and hunting buff, dove headlong into his chosen field at the Minneapolis V.A. Medical Center as Assistant Chief and Chief of the Psychiatry service and Director of the University’s Addiction Medicine fellowship program. His accomplished body of work then led him to a Professorship at George Washington University and leadership positions in treatment and research at the National Institute of Alcohol Abuse and Alcoholism (NIH), utilizing meaningful research data to develop transformative treatment modalities that deviated from more classical approaches that had been practiced from their Minnesota 1950s beginnings.

Returning to Minnesota in 2009, he practically applied those principles as the founder of Alltyr . . . a downtown St. Paul entity that Dr. Willenbring describes as “a clinic, not a program.” He did not accept the standard substance abuse treatment plan that he believed used “rehabilitation as just an introduction to Alcoholics Anonymous (AA), the 12 step abstinence-based program.” Rather, he developed a treatment methodology that utilized a variety of clinical tactics, found by many working in this realm to be every bit as effective as older strategies.

The number of Americans with addiction problems are staggering — e.g. nearly 20 million are afflicted with an alcohol use disorder and the number of people in treatment for prescription opioid overuse has quadrupled in recent years, as — sadly — so have the number of deaths from heroin overdose. Mark enthusiastically describes how Alltyr patients are treated: • Care is individualized according to patients’ needs with treatment modalities research oriented and evidence based.

• Patients are approached by the clinician “as would an old fashioned psychiatrist with in-depth history taking and dialog.”

• Addiction is treated “like a chronic medical illness.”

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March/April 2017

•

Co-morbid conditions (e.g. depression, anxiety, ADHD) are treated concurrently with the substance abuse.

• Motivational interviewing is employed — e.g. the alcoholic learns that in up to 60%, genetics play a prominent role “so lack of will may not explain prior treatment failures.”

• Length of treatment time is variable; not the usual programmatic 28 days.

• Suboxone (buprenorphrine) is appropriately used — could be long term/open-ended — to block drug “highs” and diminish cravings.

• High-risk behavior is identified and shared with patients for future avoidance purposes.

• Family members and close friends, using caring compassionate support, are prominently incorporated into the treatment plan whenever possible.

Dr. Willenbring did not succumb to the passive acquiescence of accepting the standard treatment plan preceding a classical AA approach (which continues to be an effective treatment of choice for many). Though controversy may exist on how best to care for this substance abuse population, the acceptance, via his numerous articles and presentations, has played a prominent role in combatting this wide-spread problem. Recognition and acclaim of his treatment pattern by patients and other clinicians — as reflected in numerous media communications (e.g. NBC, NYTimes, NPR) and honors (e.g. Distinguished Fellow, American Psychiatric Association; Emmy Award for HBO documentary series; V.A. and NIH Awards for Excellence and Outstanding Services) — speak to Dr. Mark’s gratifying successes. We are proud to further honor this innovative and dedicated pioneering physician as our newest Luminary.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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