Summer 2022
Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Tackling Substance Use Disorders
In This Issue: • • • •
Meet the New TCMS CEO Advances and Opportunities for Treating SUD Colleague Interview with Cuong Pham, MD 2021 Charles Bolles Bolles-Rogers Award
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CONTENTS 3
VOLUME 24, NO. 2 SUMMER 2022
IN THIS ISSUE
Gaining the Upper Hand By Thomas E. Kottke, MD, MSPH
4
PRESIDENT’S MESSAGE
Together We Can Make a Difference By Zeke J. McKinney, MD, MHI, MPH
5
YOUR VOICE
Drug Use and the Criminalization of Vulnerable Communities By Ryan Greiner, MD and Mark Nupen, MD Page 4
6
TACKLING SUBSTANCE USE DISORDER
•
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COLLEAGUE INTERVIEW:
A Conversation with Cuong Pham, MD
Lessons from the Pandemic: Addiction as a Social Disease By Chris Johnson, MD •
12 • Epidemiologic Perspective on Substance Use and Drug Overdose in Minnesota: Key findings, novel insights, and innovative public health surveillance strategies By Nate Wright, MPH 14 • Innovative Therapies for the Treatment of Addiction By Sheila Specker, MD Page 6
16 • Learning to Love Through Addiction and Loss By Sara Polley, MD 18 • Why Prescribing Suboxone Has Enriched My Practice By Javad Keyhani, MD 20
Behavioral Health Integration: Why Minnesota Needs to Keep Going By Paul Goering, MD, Tani Hemmila, MS and Claire Neely, MD •
Page 24
24 • Historic Win for Minnesota in Saint Paul: Tobacco Control Policy Achieved Through Community Advocacy By Kate Feuling Porter, MPH and Jeanne Weigum, MSW 26
•
Summer 2022
22 • The State of Minnesota’s Medical Cannabis Program By Nicholas Lehnertz, MD, MPH, MHS and Chris Tholkes, MA
Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Tackling Substance Use Disorders
ENVIRONMENTAL HEALTH:
Fossil Fuel Addiction Affects Us All By Mike Menzel, MD and David Hunter, MD
27
Gregory J. Beilman, MD Receives the 2021 Charles Bolles Bolles-Rogers Award Career Opportunities
28 Page 27 MetroDoctors
FUTURE PHYSICIAN LEADERS
Education in Addiction Medicine: Progress, Not Perfection By Elizabeth Babkin (MS4) and Thomas Marcroft (MS4) The Journal of the Twin Cities Medical Society
In This Issue: • Meet the New TCMS CEO • Advances and Opportunities for Treating SUD • Colleague Interview with Cuong Pham, MD • 2021 Charles Bolles Bolles-Rogers Award
As the number of Americans who die from drug overdoses continues to rise, MetroDoctors looks at efforts underway to understand and respond to this epidemic. Articles begin on page 6.
Summer 2022
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Summer Index to Advertisers
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
TCMS Officers
Editor-in-Chief: Thomas E. Kottke, MD, MSPH Managing Editor: Nancy K. Bauer Editorial Board Members: Clare Buntrock, Medical Student Carol Coutinho, Medical Student Dennis Cross, MD Peter J. Dehnel, MD Edward P. Ehlinger, MD, MSPH Robert R. Neal, Jr., MD Lynne Ogawa, MD Richard R. Sturgeon, MD Production Manager: Sheila A. Hatcher Advertising Representative: Betsy Pierre Cover Design by Amber Kerrigan MetroDoctors (ISSN 1526-4262) is published quarterly by the Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. 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. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@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 Nancy Bauer at (612) 623-2893.
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Summer 2022
President: Zeke McKinney, MD, MHI, MPH Secretary: Cora Walsh, MD Treasurer: Alex Feng, MD, MBA Past President: Sarah Traxler, MD, MSPH At-large: Ryan Greiner, MD
Advanced Brain + Body Clinic......................13 chooseyourfish.org.............................................25 COPIC..................................................................17
TCMS Executive Staff
Crutchfield Dermatology...................................... Inside Front Cover
Becky Timm, MA, CEO (612) 362-3715; btimm@metrodoctors.com
Deaf & Hard of Hearing Services.................21
Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Lucy Faerber, MPH, Program Manager lfaerber@metrodoctors.com Patrick Jones, Director of Finance and Operations pjones@metrodoctors.com Amber Kerrigan, Program Manager (612) 362-3706; akerrigan@metrodoctors.com Kate Feuling Porter, MPH, Senior Program Manager (612) 362-3724; kfeuling@metrodoctors.com
Lakeview Clinic..................................................27 Medcraft................................................................19 Minnesota Department of Health Office of Medical Cannabis.................. 2 Orthopedic Trauma Department, Regions Hospital...................................... 9 PrairieCare.......................... Outside Back Cover St. David’s Center................Inside Back Cover
JOIN MINNESOTA’S MEDICAL CANNABIS PROGRAM! Approved health care practitioners can certify patients for Minnesota’s Medical Cannabis Program, which provides a treatment option for people who are facing debilitating medical conditions. For more information on how to enroll, qualifying medical conditions, and more, visit mn.gov/medicalcannabis.
Office of Medical Cannabis 651-201-5598 1-844-879-3381 (toll-free) health.cannabis@state.mn.us
MetroDoctors
The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
By Thomas E. Kottke, MD, MSPH Editor-in-Chief, MetroDoctors
Gaining the Upper Hand “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” Since 1980, these 25 words in a brief letter to the editor of the New England Journal of Medicine by Porter and Jick have been cited more than 400 times to promote the prescription of narcotics. Purdue Pharma, in particular, used them to market OxyContin and encouraged physicians to use the opioid with impunity. At the same time, wholesale distributors ignored signs of abuse as their profits soared. The gravy train for opioid manufacturers and distributors may be coming to an end, but the human suffering they caused isn’t. Over the past 20 years, 10,000 Minnesotans have died from drug overdose, and mortality from drug overdose jumped 34% between 2019 and 2020, driven to a large extent by synthetic opioids like fentanyl. The events that precipitate substance use are diverse, the substances being used are many, and the needs of individuals vary. Therefore, the solutions proposed by the authors in this issue of MetroDoctors are many and diverse. Some address opioids, some address alcohol, and some address tobacco. Others propose innovations in service delivery, and still others propose new curricula. What they all have in common is seeking to understand. Not moralize. Not shame. Understand. It would behoove our politicians to do the same and consider the policies of Portugal and Finland that have produced promising results. The substrate that nourishes substance use disorder — despair from poverty and lack of opportunity — must be addressed. While most newspaper readers will know that per capita alcohol consumption increased during the pandemic, fewer will be aware that suicide rates in Minnesota have been rising since the year 2000, driven by a rise in death by suffocation. We need to find and address the root causes. Those who take advantage of human frailty to market their products don’t deserve the empathy we give our patients. The drug companies, the tobacco companies, the alcohol producers must be held accountable. The FDA needs MetroDoctors
The Journal of the Twin Cities Medical Society
to hear that you support the proposed menthol ban — right now! They are certainly hearing otherwise from the friends of Big Tobacco. Periodic escape from daily life is not inherently pathological; everyone seeks it. Religious experience, physical activity, meditation, or yoga are frequent vehicles. Escape can become pathological, however, when it is fueled by opioids, alcohol, or other drugs. By assisting in making periodic escape safe and effective, healers can help their patients achieve their goal without harm to themselves or to society. For physicians on the edge for whatever reason — substance use disorder, family break-up, financial difficulties, despair — the Physicians Wellness Collaborative offers confidential resources (https://www.metrodoctors. com/pwc). In closing, I’d like to welcome three new members to the MetroDoctors editorial board: Drs. Lynne Ogawa and Dennis Cross, and medical student Carol Coutinho. Lynne is a family physician who practiced for many years in St. Paul. She brings that experience to her current position as Medical Director for Saint Paul – Ramsey County Public Health. Dr. Cross practiced nephrology for many years but says that his true passion is general internal medicine. An associate medical director at HealthPartners health plan, Dennis also provides medical hospice services at Our Lady of Peace in St. Paul. Carol is a 3rd year medical student at the Twin Cities campus and has been a TCMS advocacy fellow. One of her interests is the intersection of social justice and sports medicine. I am excited about the breadth of experience and perspective that these three new members bring to the MetroDoctors editorial board.
Summer 2022
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President’s Message
Together We Can Make a Difference ZEKE J. McKINNEY, MD, MHI, MPH
There are so many difficult events happening in the world right now. Locally, we continue to face intimidating issues of health inequities, including gun violence sometimes involving local law enforcement, disparities in access to and quality of health care, and entrenched environmental health hazards harming communities differentially. At a national level, we are challenged with politically-motivated public health guidance, legal challenges to accessing safe reproductive care, dehumanization of disenfranchised populations, and treatment of substance abuse as a crime rather than an illness. Global events impacting us here include limited and variable COVID-19 prevention, the Russian invasion of Ukraine, and the overarching specter of climate change. This reiteration of these abhorrent problems is not to be pessimistic, but rather to emphasize why TCMS exists. We believe it is our responsibility to use our power and privilege as physicians to advocate for better health in our community. Whether that community be here in the Twin Cities, in the United States, or around the world. We want to empower you by providing you the opportunities to become engaged in ways you may not be able to in your everyday work. We must be the organization that stands up for great justice, even when, and especially when others do not. The spirit of public health is to protect the most vulnerable, and that is where our efforts will continue to focus. So we are listening! Please feel free to send us any ideas you want to pursue and we will do our best to try to facilitate you, and we encourage you to elicit ideas from the community. As we are completing our transition to a free-standing organization, you will start to see a number of new ways in which we seek your feedback and your participation. Because we will not be able to tackle everything, we are developing more systematic approaches to how we prioritize and operationalize our efforts. Our hope is to become even more effective in collaborating with community partners and growing resources to support local public health efforts. All of which relies on your involvement. We are extremely excited to proceed in this way as we welcome Becky Timm, MA, to the TCMS leadership team as our new CEO as of May 16, 2022. Becky has over two decades of experience as a nonprofit executive locally and has helped transform organizations into sector-leading nonprofits. In particular, she has served as Executive Director for two neighborhood associations in Minneapolis, as well as on the boards of many local nonprofit organizations. A native to Minnesota, Becky’s background includes working extensively with community health programs, including experience with the impact of health inequities on Twin Cities neighborhoods, food systems, and justice. She is an accomplished communicator, trainer, and project manager, and was named a City of Minneapolis Health Hero Awardee for her work developing community-informed programming. Becky’s nonprofit expertise, her successful record as a leader, and her passion for equitable community health are just a few of the tremendous assets she will bring to our organization. Becky will be working closely with the TCMS staff and Board to not only continue our ongoing efforts, but to also lead us to even greater successes. In the short-term, please volunteer to be a mentor, preceptor, or to even allow someone to shadow with you; share our work and our statements on social media; engage with legislative entities to support work that advances public health; encourage others to join us; and participate in community events. You will see plenty of opportunities for all of these in coming months. If you are engaged in work you think we can support, let us know; if we can back you up in what you are doing, we aim to do so. As your President, I am grateful for the opportunity to lead this organization during this extremely exciting time of our growth! Thank you for your ongoing support of all of the great work that we can do when we all work together. 4
Summer 2022
MetroDoctors
The Journal of the Twin Cities Medical Society
YOUR VOICE
Drug Use and the Criminalization of Vulnerable Communities The “War on Drugs” was initiated in June of 1971 when Richard Nixon dramatically increased the scope of federal drug control policies. As part of that initiative, he expanded the penalties for drug offenses through mandatory sentencing that ultimately served to enshrine generational trauma into families and communities that historically (and continually) have been the subject of racist and suppressive government policies. That legacy continues to this day despite the recognition that government-sanctioned oppressive and discriminatory approaches to drug use continue to ignore the impetus of that use: unmet mental health needs grounded in the disenfranchisement of vulnerable communities through the restriction of meaningful participation in the economic, social, and political opportunities of this country. It is time to address this historic inequity and end the criminalization of drug use. Coupled with investments in proven methods of reducing harmful substance use, we can end the “War on Drugs,” begin a “War on Health Inequity,” and propagate evidence-based methods to address the mental health challenges and general health inequities our communities face. As a matter of historical grounding, the use of mind and body altering substances by humans has been part of various cultures for thousands of years. These substances have served roles in medicine, religion, spirituality, and simply as commodities in socially approved ways. Psychologically and biologically active substances are part of our environment, adapted to human and animal biology, and do not intrinsically have moral properties. Rather, modern industrial societies have assigned moral and legal properties to their use for various reasons. In the United States, biologically harmful substances, such as alcohol and tobacco, have remained a protected class of drug use, despite the enormous health costs and impact on communities. At the same time, other less harmful or arguably unharmful drugs, including those with legitimate medicinal purposes, have been classified as illegal to use and/or declared to have no legitimate medical purpose. These facts expose the true intent of drug use criminal penalties.
By Ryan Greiner, MD and Mark Nupen, MD
MetroDoctors
The Journal of the Twin Cities Medical Society
The “War on Drugs” eventually became recognized as a deliberate effort at incarcerating increasing numbers of Black Americans, as well as an effort to shift public impression of the counterculture movement that began in the 1960s. This was not the first time drug laws were used to target a particularly vulnerable minority group. The first anti-marijuana laws in the 1910s and 1920s were directed at Mexican migrants and Mexican Americans. In the 1870s, the first anti-opium laws were directed at Chinese immigrants. Drug laws have become a political tool for tapping into the social anxiety of voters around perceived threats to the white majority. Today, despite representing only 13% of the U.S. population, Black people are 25% of those arrested for drug use and possession, even though Black and white people use and sell drugs at similar rates. The “War on Drugs” has also created an illicit drug trade that has led to an overdose epidemic due to illicitly manufactured fentanyl and fentanyl analogues. Finally, drug use addiction and disorder are serious concerns that are public health issues, not criminal justice issues. Most drug abuse is rooted in untreated mental health disorders. Other aspects of the drug trade are rooted in the inability for historically suppressed members of our society to access the cultural, societal, and economic advantages felt by privileged communities. Countries like Portugal have demonstrated that decriminalizing drug use (20 years ago) and re-investing those criminal justice dollars into treatment for mental health disorders decreases drug use rates, drug overdoses, and saves substantial amounts of money. Now is the time for change in Minnesota — for the medical community to adopt evidence-based, scientifically supported policy changes around drug use decriminalization and shift that focus from criminalizing vulnerable communities to investing in their health and well-being. Citations: • Felix, S., Tavares, A., Portugal P. “Going after the Addiction, Not the addicted: The Impact of Drug Decriminalization in Portugal.” Institute of Labor Economics. Accessed https://ftp.iza.org/dp10895.pdf. • Vicknasingam B, Narayanan S, Singh D, Chawarski M. Decriminalization of drug use. Curr Opin Psychiatry. 2018 Jul;31(4):300-305. doi: 10.1097/ YCO.0000000000000429. PMID: 29746420. • Drug Policy Alliance. “It’s Time for the U.S. to Decriminalize Drug Use and Possession.” Accessed https://drugpolicy.org/sites/default/files/documents/Drug_Policy_Alliance_Time_to_Decriminalize_Report_July_2017. pdf.
Summer 2022
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Tackling Substance Use Disorder
Colleague Interview: A Conversation with Cuong Pham, MD
D
r. Cuong Pham is Internal Medicine and Pediatrics trained and board certified in Addiction Medicine. He was born in Vietnam and escaped as a refugee at an early age. He was raised in Little Canada, Minnesota and is a proud life-long Golden Gopher from his undergraduate education to residency training. Currently he splits his time doing hospital medicine and addiction medicine at the University of Minnesota and primary care at the Community University Health Care Center. He has several roles at the University of Minnesota Medical School in diversity, equity and inclusion as well as the current president for Minnesota Doctors for Health Equity. He has a focus on immigrant health and more recently has been doing community-engaged and advocacy work on addiction with communities of color.
In talking about your work, you note that the opioid epidemic has struck the surrounding community hard, especially the Native American and Somali populations. •
What makes these two groups more vulnerable?
•
How have you used their cultural beliefs and practices in addressing their opioid epidemic?
I believe the unifying stories of the Native American and Somali communities are about displacement, trauma, and systemic racism which have resulted in distrust in the medical institution and governmental institutions. Many of us were not taught in school about the stolen lands of the Obijbwe and the Dakota in Minnesota, the forced displacement onto reservations, and the violent erasure of Indigenous culture and generational knowledge via boarding schools. Even our own academic institutions have previously done research on Native American communities without their consent and without respecting the sovereignty of Native American data. Whereas Somali youth, who often are refugees of war, struggle to assimilate into American life and Somali families are afraid to acknowledge addiction due to stigma. Furthermore, our healthcare systems continue to fail to screen for opioid use disorder in the community by assuming that Muslims are immune to addictions. As a result, both of these communities face barriers to care in combination with being victims of implicit bias and systemic racism, fueling a cycle of health disparities in addiction.
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From a public health level, I value using cultural competency to understand the common threads of the majority in a specific community which sometimes is surrogate to understand social determinants of health. However, I consider a person’s identified community as only a starting point in my interactions. It is both cultural humility and social determinants of health equity that helps me acknowledge my blind spots for all cultures and communities and prompts me to refocus on the truth that each individual has their own unique lived experiences. From an individual level, I acknowledge, share, embrace, and normalize community or cultural practices in order to cultivate positivity, healing, and a welcoming presence in my research or clinical work. It also means I strive to create conversational and physical spaces with people who are from the community because they are the most authentic, trustworthy, and transparent in these practices. For instance, my research team and clinical volunteer teams have been majority Black, Indigenous, People of Color (BIPOC) and are often identified as Native American or Somali.
Traditional health fairs in our community have not been thought to be an effective way of improving health. What are the aspects of the community health fairs with which you have been involved that make them successful? Have you done an evaluation of their efficacy? Success comes from community-engaged and community-focused work. I focus on sharing my space with stakeholders in the MetroDoctors
The Journal of the Twin Cities Medical Society
community. It is important as outsiders to be welcomed into the community first before entering through the doors of their homes. Even once I sit down with them, I am mindful of letting them lead the conversation. Only then, I might leverage my privileges and expertise to meet desires and needs in collaboration with each community. My job is not to use their resources of time and money to fit my academic goals but rather to collaboratively align more of my institutional resources to meet their goals. For instance, after years of working with me and my research assistant Koushik Paul, the Little Earth of United Tribes protectors, elders, and leaders in Minneapolis asked us to help with Narcan and CPR training in their community. Overdoses from opioids were increasing at Little Earth and children were watching their family members suffer. Multiple organic conversations prompted the community members to request additional health services to increase engagement around opioid education. Fortunately, my team was already partnering with the Mobile Health Initiative at the University of Minnesota who had the resources to come to the community. Ultimately, Little Earth’s goal was to train as many people as possible of all ages about Narcan and CPR in order to save lives. Even the Native American youth were helping us do the training at the community health fair and on their own with their families. Empirically, over the years, we have heard multiple stories of children and family members saving lives using the skills learned at these trainings. Researching the efficacy of these trainings would be future steps. However, it is important to acknowledge evaluations and studies of any sort require permission from the community. All metrics and data belong to the community, and it is important to understand that Tribes are sovereign nations and have the right to control all information that comes from their community. Plus, opportunities should be given to the community to be equal researchers and evaluators in order to accurately interpret and understand resulting data.
Are you aware of any efforts with law enforcement to short circuit the addiction vicious circle? We need to educate the public and our governmental agencies, including law enforcement, on how addiction affects the brains of people using drugs and how addiction is a chronic disease as much as diabetes and hypertension. Often the lines of people who sell or share drugs versus use drugs are blurry or do not exist. Unfortunately, the current use of the court system and our law enforcement focuses on punishing people with addiction as a deterrent rather than offering treatment or supporting recovery. This is definitely an area where health systems need to collaborate with these agencies to increase their advocacy for people with addiction. It is important that our law enforcement, drug courts, and child protective services begin to understand the social determinants of health that affect our communities; only when families are kept intact, and addiction treatment is supported can justice and equity be restored.
Would legalization of marijuana in Minnesota be helpful to the overall substance abuse problem? It is not clear that legalization of marijuana in Minnesota would help with the overall drug use. However, decriminalization and legalization of marijuana are important steps for racial justice and health equity since arrests and incarceration involving drugs disproportionately affect higher numbers of BIPOC compared to whites. Furthermore, steps to regulate the safety of marijuana would reduce the chances of marijuana being laced with other drugs like fentanyl. Current drug laws do not deter use of drugs or decrease use disorders. It has not been shown that the states that have legalized marijuana have resulted in the increased use of marijuana. Still, it will be important that legalization will need to be concurrent with increased education of addiction, and access to treatment programs in particularly vulnerable communities.
Should quantity limits on prescriptions such as Oxycodone be instituted to lessen the risk of physician-caused substance abuse? Quantity limits on opioid prescriptions may decrease misuse, potential overdoses, or decrease occurrences of opioid use disorders. I also think creating restrictions may cause unintended circumstances and harm those clinically needing opioids to safely manage their pain. I think it will be more crucial to focus on training healthcare providers on the safe and proper use of opioids, easier access to the Minnesota Prescription Monitoring Program to electronic medical records, increased screening for OUD in all health systems, improved access to mental health services, and education on drugs in our school systems.
Has there been any success in mitigating the fentanyl problem? Today all the synthetic opioids on the streets in Minnesota are fentanyl and less likely heroin. Fentanyl is even coming in the form of pills. Previously we recommended test strips to help people discern fentanyl from other opioids but now we just assume that all forms of opioids from the streets are fentanyl. Certainly, decreasing the flow of fentanyl from other countries is important to prevent morbidity and overdose deaths. I think the more direct question is how do we prevent overdose deaths and related health problems from opioid use. I believe the focus should be on harm reduction to help engage people with substance use disorder, which will help destigmatize addiction and allow more people to feel more comfortable to ask for treatment. Harm reduction includes teaching people how to safely use clean needles, providing easier and free access to Narcan, and conducting education for lay CPR members of the community. As mentioned before, it is crucial that we make access to buprenorphine easier and cheaper than opioids on the street. (Continued on page 8)
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Summer 2022
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Tackling Substance Use Disorder Colleague Interview (Continued from page 7)
Given the difficulty caused by inadequate technical equipment to do telemedicine, are there opportunities for a community member to have access to a temporary setup? Do you suggest a better solution? I think the more proximal future of telemedicine is the actual use of basic phone visits. Due to COVID-19 and temporary law changes from the DEA for buprenorphine treatment for opioid use disorder (OUD) and telemedicine billing, my research team wanted to understand the acceptability, preference, and barriers of phone versus video visits for patients with OUD and providers at a variety of urban clinics. Our preliminary results show that patients like all three modes of clinical visits: phone, video, and office. Ultimately patients want a menu of choices that fit their lives and makes access to care easier and more affordable. Phone visits remove the barrier of transportation, time off from work, and need for child care, and at the same time, it does not require start-up costs or education for the majority of patients or providers. On the other hand, video visits require a higher amount of tech literacy, updated technology, and ongoing troubleshooting support for providers. The crucial point is that we need to make our care more patient-centered, community-centered, and culturally-centered to decrease the health disparities and inequities in care. Furthermore, when it is easier and cheaper to get buprenorphine from our healthcare system rather than buying heroin or fentanyl on the streets, people will invariably seek out treatment. I believe telemedicine will permanently be part of that road map for improving access to care in all parts of clinical care.
Are you aware of clinics other than Community University Health Care Clinic (CUHCC) that have effective and active interaction with the community? Do you know if students and staff work in any of those other sites? CUHCC is part of the consortium of federally qualified urban health networks (FUHN) across Minnesota. The goal for all these community centers is to treat underserved areas and provide comprehensive health services. This is also true of the many neighborhood clinics that have been embedded within the community like Smileys, Broadway clinic, Native American Community Clinic, and Indian Health Board. In order to effectively do this work, every clinic needs to engage with their local environment and community. Often this includes having a community advisory board and ongoing listening sessions. CUHCC has had the privilege of training thousands of students of all health professions and residents over the years because of our direct connection with the University of Minnesota Academic Health Center. Students from the university are expected to have a diversity of clinical experiences. Often students share their experiences at other clinical sites which can bring important insights to improve the care at CUHCC. 8
Summer 2022
How do you leverage your work on addictions with your efforts with Minnesota Doctors for Health Equity? There are very few medical experts or physicians who comfortably sit at the intersection of addiction and equity work. To illustrate this, according to the American Board of Preventive Medicine, there are only 82 Addiction Medicine board certified physicians in the state of Minnesota. The majority of these physicians are just learning about health equity work. I am fortunate to be part of Minnesota Doctors for Health Equity (MDHEQ) as one of the original founders, board members, and current president. This non-profit organization has introduced me to leadership across multiple hospital systems which has given me opportunities to educate about my interest in addiction and equity. For instance, I have been a participant and presenter at Hennepin Healthcare’s Project ECHO on opioid use disorder, which is a tele-education forum to bring local experts to the healthcare providers. Now I am in the process of forming an innovative Project ECHO on the intersection of opioid use disorder (OUD) and race/racism and equity. This new Project ECHO will bring conversations, connections, and collaborations with communities of color in Minnesota and healthcare systems in hopes of exchanging ways to make OUD care more culturally-centered and community-centered. I am also privileged to have regular conversations with the Commissioner of Minnesota Department of Health Services at our MDHEQ board meetings about topics such as addiction services, mental health services, and the use of telemedicine. I have also participated on a medical cannabis physician working group for the Department of Health which provided a forum for me to infuse health equity in the implementation of medical cannabis.
Does Minnesota Doctors for Health Equity have ongoing working relationships and activities with Dean Ana Nuñez, MD and the office of Equity and Diversity? Does that presumed collaboration have a direct effect on Medical School clinical programs and curriculum design? I chair the University of Minnesota Graduate Medical Education (GME) DEI advisory workgroup, and I am also the Associate Vice Chair of DEI for the Department of Medicine. Like many others in MDHEQ, I wear multiple hats at the University of Minnesota Medical School. Invariably my work with MDHEQ informs my collaborations with GME, department of medicine, and Dean Ana Nuñez. Furthermore, many MDHEQ board members and membership, which include faculty and trainees, interact or hold significant roles in the University of Minnesota Medical School and their training programs and thus their diversity of expertise have a far-reaching impact on health equity education. Our membership also has leadership roles in multiple health systems as well as the Minnesota Department of Health and Department of Human Services.
MetroDoctors
The Journal of the Twin Cities Medical Society
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Tackling Substance Use Disorder
Lessons from the Pandemic: Addiction as a Social Disease
I
t will take years and the labor of a generation of scholars before we truly know the cost of the COVID-19 pandemic. And even then, a true figure may escape us. As I write this in March 2022, there have been over 990,000 deaths due to COVID-19 in the US and more than five million deaths worldwide. But beyond deaths due to complications from the virus itself, there are other costs that we can only begin to estimate. The collective psychological trauma that was COVID continues to wreak havoc on our social and mental health. Indeed, many articles have been written about the parallel mental health pandemic that has evolved alongside the infectious disease one. The truth of this observation may have its clearest manifestation in the field of Addiction Medicine for here we see how all the stressors of the pandemic combined to make a bad situation truly horrific. COVID has been an emphatic reminder that our individual health is intimately connected to the health of those around us. There is an opportunity here to recognize that and incorporate those lessons in how we approach mental health and addiction treatment. Prior to COVID, the opioid epidemic was already a crisis. It was considered one of the most important public health emergencies of our time and rightly commanded the headlines of our news media and the attention of our political leaders. In 2019, overdose deaths from opioids reached an all-time high of 50,000, most of which were due to illicitly made fentanyl. Then COVID hit, and a crisis became By Chris Johnson, MD
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a catastrophe. According to CDC data, from April 2020 to April 2021 there were over 100,000 overdose deaths in the United States — the highest ever — with no less than 75,000 due to opioids, a mind boggling 50% increase from two years earlier. And this dangerous increase was not limited to opioids. Alcohol sales increased 50% during the pandemic and alcohol-related deaths increased 25% between 2019 and 2020, 10 times the increase of prior years. These dramatic spikes demand an explanation. There are many articles that discuss the increased stressors people have been under since the pandemic began and they are familiar to anyone reading this. Trying to stay informed, people increased their consumption of television news and began to fear for their very lives as the death counts were reported with grim regularity. While this was happening, the usual social supports people rely on in times of stress — each other — were severely limited by the stay-at-home mandates. In addition, people began to wonder if they were going to have a place to live or food on the table as jobs disappeared and rent checks became due. Parents with school-aged children faced their own challenges as they tried to work from home and make sure their children were mastering the new modality of virtual learning. Finally, there was the added stress of failed leadership, especially at the national level, which caused many to feel a sense of abandonment — that they were on their own to navigate this deadly crisis. But why specifically should these increasing fears be associated with a rise in addiction? I would like to argue that
addiction — or at least the behavior that is its immediate antecedent — is perhaps best understood as a means of pathologic coping in response to stress, both on the individual and community level. I do not claim complete originality in this idea. The concept of addiction as a response to an allostatic load (the cumulative burden of stress and life events) has been discussed for years. In this view, addiction is both an individual illness — for which each patient has their own unique story — and a community illness, in which whole populations can be put at risk under the right circumstances. However, many of the articles that discuss risk factors for addiction typically emphasize the individual aspect — with genetics often listed as the primary risk factor, usually followed by coexisting mental health disorder. I do not doubt either’s
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importance. In fact, such an approach is understandable in that we interact with patients — and bill them — in just such a one-on-one fashion. But I think this underestimates the impact of environment on addiction. Further, I think there is compelling data that the individual approach to treatment is inadequate, as well as inefficient, and that to reduce the burden of addiction on the population we would be better served applying those resources elsewhere. We can look at our own experience with opioids, as well as the experience of our European counterparts, to better understand this. In our recent past, we have watched with frantic alarm as deaths from opioids began its terrible rise in the early 2000s, driven by prescriptions. And while the tragic deaths of such prominent figures as Prince and Heath Ledger tell us that opioid addiction can affect anyone, when you look at the nation as a whole, one group felt the impact of opioids more than any other — middle-aged, working-class whites. In their 2020 book Deaths of Despair, Nobel prize economists Angus Deaton and Anne Case demonstrated that deaths from opioid overdose and alcoholism were experienced by those white Americans without a four-year degree at a rate 4x higher than their more educated counterparts. It seems difficult to believe their genetic makeup was so calamitously different. Another example of the importance of environment would be our experience in the Vietnam War. According to SAMHSA, about 0.2% of the adult population of the US suffers a heroin use disorder at any given time. Yet in 1971, a congressional investigation of Vietnam servicemen found as many as 20% were addicted. It is similarly impossible to believe a random conscription process would result in servicemen having a genetic predisposition to addiction 100 times more common than the general population. Even more compelling, their recovery rate once they got back home was almost 90%, much higher than measured recovery rates of those who develop addiction here. The reason for the unusual recovery rate seems clear — once the hardship, boredom, and MetroDoctors
stress of war was over, the compulsion to use ended as well. We must resist the temptation to attribute the increased deaths from opioids during the pandemic to reduced “access to treatment.” It is true that patients experienced some degree of this due to treatment facilities observing new social distancing protocols and increased difficulty in finding providers licensed to prescribe Medical Assisted Therapy. But the truth is, the United States has enjoyed the lion’s share of recovery resources in the world and still we have the worst outcomes. This has been true for many years. According to the 2019 report of the European Monitoring Centre for Drugs and Drug Addiction, the United States has 10 times the overdose death rate as the European Union, yet we possess far more treatment facilities than they do. The EU has a total of about 2,500 centers for its 750 million people, compared to the US which has over 14,000 for its 330 million. This means we have more than 10x the number of treatment facilities per person. In addition, the United States has far more peer support resources than any other country with about 40% of Narcotics Anonymous chapters in this country alone. Clearly, the presence of a robust and profitable recovery industry has not resulted in better outcomes for our patients. It is for this reason I think more needs to be done at the society level rather than the clinic level when it comes to addiction. I do acknowledge that Medical Assisted Therapy has clear survival benefits for patients with Opioid Use Disorder. And I do not oppose making it more available. But the truth is our profession cannot compensate for the adversity many Americans experienced due to COVID. Nor even to the stressors they experienced before COVID. In fact, the American medical profession contributes to the population’s distress with our predatory pricing. A 2011 study by Auerbach and Kellerman showed that medical costs wiped out an entire decade’s worth of wage growth for the average American family, the kind most vulnerable to social and environmental stressors. So rather than continuing to
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funnel scarce resources into a profession that is already overpriced and inefficient, we should be looking for ways to help the vulnerable portions of our population feel less vulnerable. We can take lessons from other countries that are already outperforming us in this regard, whether that is strengthening the social safety net, making education more equitable, or reducing the cost and complexity of health care. The pandemic has reminded us of how we as a society have to work together to stay healthy. And we in the medical profession cannot medicate away a toxic society. Dr. Chris Johnson is a Board Certified Emergency Physician currently working for Allina Health. He is a board member of Physicians for Responsible Opioid Prescribing and served as Chair of the Minnesota Department of Human Services Opioid Prescribing Work Group. He can be reached at: chrisj442@ gmail.com or website: endtheopioidcrisis.com.
N O M IN A T IO N S F O R
CHARL ES B OLLES B OL L ES-ROGERS AWARD Candidates for this “Physician of Excellence” award are nominated by their peers for achievement or leadership in medicine, contributions to clinical care, teaching and/or research. Recipient is selected by the TCMS Foundation Board of Directors. NOMINATIONS ARE DUE BY JULY 31, 2022. Nominate a colleague at metrodoctors.com/awards
Summer 2022
11
Tackling Substance Use Disorder
Epidemiologic Perspective on Substance Use and Drug Overdose in Minnesota: Key findings, novel insights, and innovative public health surveillance strategies
F
rom 2000 through 2021, over 10,000 Minnesotans have died from a drug overdose.1 Furthermore, preliminary 2021 death data indicate that drug overdoses will surpass falls as the leading cause of injury mortality in Minnesota, highlighting the alarming rise in drug overdose deaths over the past two decades.2 Currently, the drug overdose epidemic is characterized by novel psychoactive substances, including synthetic opioids, psychostimulants, and benzodiazepines. Drug overdose deaths, however, are just the top of the injury pyramid. For every overdose death there were 11 nonfatal hospital-treated drug overdoses in 2020.3 This article highlights key findings and emerging trends in drug overdose deaths and nonfatal hospital-treated drug overdoses in Minnesota. This includes discussion of the limitations of current public health surveillance systems and improvements being undertaken to provide comprehensive and timely information to support prevention efforts around drug overdose and substance use in Minnesota. Fatal Drug Overdose
Analysis of death certificate data has shown that the Minnesota drug overdose mortality rate increased by 34% from 2019 to 2020, rising from 14.2 to 19.0 per 100,000 population.1 The increase in drug overdose deaths is driven primarily by opioids, with about 60% of drug overdose deaths involving opioids.4 Much of
By Nate Wright, MPH
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Summer 2022
the growth in opioid-involved overdose deaths can be attributed to synthetic opioids, which death scene investigation and toxicology results indicate are likely due to illicitly manufactured fentanyl.5,6 Opioids, however, are not the only substances of concern. All drug categories increased in 2020.5 Of particular concern are psychostimulants, which toxicology findings indicate are primarily methamphetamine. Psychostimulant-involved deaths have virtually paralleled the increase in synthetic opioid-involved deaths, with the number of psychostimulant-involved deaths nearly quadrupling in the past six years.7 Increases in drug overdose deaths over the past few years have also been characterized by polysubstance use. For example, from 2017 to 2019, nearly 50% of psychostimulant-involved deaths involved at least one opioid; 57% of cocaine-involved deaths involved at least one opioid; and 82% of benzodiazepine-involved deaths involved at least one opioid. Across each of these categories, the contribution of synthetic opioids has grown substantially from less than 10% in 2011 to 2013 to 33% or more of deaths in 2017 to 2019.8
Furthermore, over the past 10 years, 18% of opioid-involved deaths involved alcohol.9 Death certificates are a critical data source for public health surveillance, but there are important limitations. First, death certificates are not timely. It may take weeks for a death certificate to be finalized and made available for analysis. Second, death certificates lack detailed toxicology data, with 13% of drug overdose deaths lacking any information on specific drugs involved.1 Finally, death certificate data lack circumstantial information on the events leading up to and at the time of death that are crucial for prevention and response efforts. With support from the Centers for Disease Control and Prevention, we have implemented the State Unintentional Drug Overdose Reporting System (SUDORS) that provides comprehensive and timely information on drug overdose deaths. This system collects and abstracts data from death certificates and medical examiner/coroner reports, including scene findings, autopsy reports, and toxicology findings. The goals of SUDORS are to better understand the circumstances that surround overdose deaths; improve overdose data timeliness and accuracy; and identify specific substances causing or contributing to overdose deaths.10 SUDORS has shown that four out of five people who died of a drug overdose in Minnesota had an identified opportunity for intervention.11 This includes a recent release from institution (e.g., hospital or jail/prison), history of prior overdose, an
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identified mental health problem, history of substance use treatment, evidence that a bystander was present, or the drug use was witnessed. Prevention, treatment, and response efforts that address these opportunities for intervention are supported by MDH, in partnership with local organizations and communities. Nonfatal Drug Overdose
In 2020, for every one overdose death, there were 11 nonfatal hospital-treated overdoses.3 Emergency department (ED) visits for drug overdose continue to increase, rising 44% from 2016 to 2020 (5,079 to 7,290 overdoses). It should be noted that this does not include visits related to alcohol use, which is a cause of a significant number of hospital visits. Based on diagnosis codes, opioids or stimulants were involved in 57% of ED visits for nonfatal overdose. From 2016 to 2020, the number of nonfatal overdoses that involved all opioids more than doubled, from 1,501 to 3,804 overdoses; heroin and stimulant overdoses increased from 2016 to 2019 but remained relatively stable from 2019 to 2020. The interpretation of hospital data is also subject to important limitations. Drugs identified in nonfatal overdoses are often self-reported by the patient or determined by presenting symptoms at the hospital; toxicology testing is often not completed. Caution is thus required when interpreting the hospital data because of a lack of detail on specific substances involved. Effective and tailored prevention strategies for populations at risk rely on accurate identification of substances involved in these nonfatal events. To provide this information, MDH developed the Minnesota Drug Overdose and Substance Misuse Surveillance Activity (MNDOSA) to understand substance misuse and drug overdose patterns.12 MNDOSA illuminates the types of substances being used in Minnesota by conducting toxicology testing at MDH Public Health Laboratory for a subset of MNDOSA cases. These results inform clinicians, community partners, and the public about substance use trends MetroDoctors
to guide prevention and treatment efforts. MNDOSA results show that amphetamines were the most common substances detected. Furthermore, substances were often detected in samples more frequently than were suspected.13 After linking hospital discharge and MNDOSA data, most importantly, 68% of MNDOSA cases were not identified through traditional hospital-based surveillance of drug overdoses; this finding is consistent with previous epidemiologic investigations.14 This result highlights how traditional surveillance methods focusing on only drug overdoses are insufficient at describing hospital utilization for substance use. Fatal and nonfatal overdoses continue to rise, with unfortunate signs that the year-to-year increase has only grown over recent time. Opioids remain the primary driver, but we are also seeing significant increases in psychostimulant-involved deaths. However, our evolving public health surveillance systems that monitor drug overdose and substance use now collect more timely and comprehensive data.
The Journal of the Twin Cities Medical Society
We have used these novel data to inform prevention, treatment, and response efforts in local communities, among first responders, and with harm reduction programs by identifying locations and populations with greater overdose burden. With drug overdoses expected to become the leading cause of injury mortality in Minnesota in 2021, better data and information can inform the work needed to change the course of the substance use and drug overdose epidemic. Nate Wright, MPH, is the Epidemiologist Supervisor of the Drug Overdose Epidemiology Unit in the Injury and Violence Prevention Section at the Minnesota Department of Health. He is the surveillance coordinator for the Centers for Disease Control and Prevention funded Overdose Data to Action initiative and is the Principal Investigator for Minnesota’s Syndromic Surveillance System. He can be reached at: Email: nate.wright@ state.mn.us; Phone: 651-201-4237. References available upon request.
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Summer 2022
13
Tackling Substance Use Disorder
Innovative Therapies for the Treatment of Addiction Introduction
Rates of substance use disorder (SUD) and particularly opioid use disorder (OUD) have skyrocketed over the last several years due to COVID-19, the increasing potency of opioids and cannabis, and the resurgence of methamphetamine. Opioid overdose deaths in the US have increased to 75,673 over the 12-month period ending in April 2021, up from 56,064 the year prior (CDC 2021). Great strides have been made in the treatment of SUD yet there are relatively few pharmacotherapies. The FDA approved pharmacotherapies for alcohol use disorder (AUD) are disulfiram, naltrexone oral and monthly injection, and acamprosate. Buprenorphine, methadone, and naltrexone are the FDA approved medications for OUD. These medications target different aspects of the complex neurobiological and metabolic systems involved in addiction. This article will highlight novel uses for gabapentin and topiramate in the treatment of AUD and a new formulation of buprenorphine for the treatment of OUD. We will also discuss neuromodulation as a potential non-pharmacologic treatment for SUD. Gabapentin (off label use for AUD)
Gabapentin is a gabapentinoid and analog of gamma aminobutyric acid (GABA), the primary inhibitory neurotransmitter in the central nervous system (CNS). However, it does not interact with GABA receptors or interfere with GABA metabolism. Instead, it acts on presynaptic voltage-gated calcium channels, which modulate the release of excitatory neurotransmitters, and indirectly By Sheila Specker, MD
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Summer 2022
increases GABA in the CNS — causing generalized neural inhibition. The mechanism of action suggests a therapeutic potential to treat AUD and alcohol withdrawal. By modulating and stabilizing central stress systems dysregulated by drinking cessation, gabapentin can return the brain to a more normal homeostatic state (Mason, et al., 2018). The use of gabapentin in AUD is supported by multiple randomized, double-blind, placebo-controlled, treatment studies that reported drinking outcomes. All study subjects received coordinated psychosocial behavioral therapy. Studies reported gabapentin reduced alcohol consumption, increased total abstinence, and decreased cravings. It had greater efficacy at higher doses up to 1800 mg/day and with initiation after ≥3 days of abstinence. Importantly, and unique among pharmacotherapies for AUD, gabapentin had a profound benefit on alcohol-related insomnia, anxiety with negative affect, and alcohol withdrawal symptoms. Gabapentin preserves sleep architecture, and its use did not result in daytime drowsiness or decreased productivity (Mason, et al., 2018; Anton et al., 2020; Cheng, Huang, Huang, 2020). One study demonstrated gabapentin with naltrexone improved
drinking outcomes over naltrexone alone for 6 weeks after drinking cessation (Hägg S, Jönsson, Ahiner, 2020). Gabapentin is not hepatically metabolized or hepatotoxic, undergoes renal elimination unchanged, and is generally well tolerated, however, there are concerns it is increasingly being misused (Hägg S, Jönsson, Ahiner, 2020). Although further studies are needed, gabapentin has shown to be a safe and effective treatment for AUD with unique benefits for alcohol-related insomnia, negative affect, and alcohol withdrawal symptoms. Topiramate (off label use for AUD)
Topiramate is an anticonvulsant that has been shown to be effective as a treatment option for AUD. Like ethanol, Topiramate enhances GABA-A receptor activity and is an antagonist of glutamate, an excitatory neurotransmitter. It works by enhancing the action of GABA while blocking the activity of two subtypes of glutamate receptors. GABA potentiation and glutamate antagonism results in generalized neural inhibition. Use of topiramate is well-supported by evidence that suggests topiramate is at least as effective as naltrexone and acamprosate (Florez, et al., 2011). Data summarized from two meta-analyses evaluating topiramate found comparable outcomes to a meta-analysis of naltrexone and acamprosate and supported topiramate as a treatment option for maintaining abstinence and reducing heavy drinking (Blodgett, et al., 2014; Jonas, et al., 2014). A meta-analysis of seven clinical placebo-controlled trials with a total of 1,125 individuals with alcohol dependence demonstrated efficacy for topiramate with higher rates of
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abstinence and lower rates of heavy drinking (Blodgett, et al., 2014). It has been shown that topiramate is an efficacious medication for reducing drinking and alcohol-related problems among patients with problematic alcohol use (Kranzler, et al., 2021). Topiramate, within the dosage range of 75-300 mg/day, could be considered a treatment option for the management of AUD. It can be initiated at a dose of 25 mg daily and can be slowly titrated up to a maximum dose of 300 mg/day, over eight weeks. Evidence does not support one firstline AUD pharmacotherapy medication over another; therefore, selection of medications for AUD should be individualized based on the patient’s needs and patient and clinician preferences. Buprenorphine ExtendedRelease Subcutaneous Injection
Buprenorphine, a partial opioid agonist, was approved in the US in 2002 for OUD and is highly effective because of its high affinity for and slow dissociation from the mu-opioid receptor. In a recent analysis of persons prescribed buprenorphine in France, patients who discontinued treatment were ~29 times more likely to die than those who remained on buprenorphine (Dupouy et al. 2017). By acting as a competitive inhibitor at the mu-opioid receptor it helps relieve cravings, suppress withdrawal symptoms, and has excellent safety and abuse liability profiles. In addition to the standard daily sublingual formulation, a new once monthly injectable provides another treatment option for those with OUD. This formulation has several advantages: greater adherence, reduced risk of diversion, allows for travel without carrying a controlled substance, eliminates risk of accidental ingestion by children, allows for uninterrupted buprenorphine therapy while incarcerated, and enables a smoother taper/discontinuation because of its unique pharmacokinetic profile. The formulation triggers polymer formation and buprenorphine is gradually released over a one-month period as the polymer biodegrades. Disadvantages are cost and need for Risk Evaluation and Mitigation Strategy (REMS). MetroDoctors
Neuromodulation: Transcranial magnetic stimulation (TMS)
Neuromodulation is an innovative non-pharmacologic treatment for SUD. TMS is gaining support as a safe and cost-effective treatment because of its capacity to target and modulate specific brain circuits involved in the neurobiology of addiction. A transient, high-intensity magnetic pulse is applied to the scalp which modulates cortical excitability and dopaminergic activity in the limbic system by altering resting membrane potentials. Neuromodulation: Transcranial direct current stimulation (tDCS)
An innovative strategy called tDCS modulates neural networks in several key areas affected by substance use. Dr. Camchong, a researcher at the University of Minnesota, has shown that individuals with AUD and longer-term abstinence have a higher synchrony between prefrontal (e.g. dorsolateral and anterior cingulate cortex) and limbic brain regions (Camchong, Stenger, and Fein 2013). Preliminary data from a clinical trial utilizing tDCS has shown that just five sessions induced promising effects on treatment outcome and frontal-striatal resting state functional connectivity (synchrony) in individuals with alcohol use disorder during early abstinence. Conclusion:
Addiction remains an under-diagnosed and under-treated illness. Understanding the neurobiology of addiction helps to guide our research and clinical practices — it forces us to think “out of the box.” This strategy will propel our addiction treatments forward. Educational opportunity: Coaching and mentoring on any addiction medication is available through Project ECHO, a weekly virtual didactic/consultation through Hennepin HealthCare. Dr. Sheila Specker is a family physician and addiction psychiatrist who is program director for the Minnesota Addiction Medicine Fellowship. This program trains physicians from any specialty in a 12-month fellowship to be leaders in the field of addiction. Dr. Specker is in the Dept. of Psychiatry at the
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University of Minnesota and has 30 years of clinical practice, research, and is medical director of a treatment program. She can be reached at: speck001@umn.edu or 612-273-9806. Co-authors Robert C. Pueringer, MD and Ingrid Podnieks, MD are Addiction Medicine Fellows and David Peter, MD, is Addiction Medicine Faculty, University of Minnesota. Contributor Isaac Yelkin is a college-bound student interested in the area of addiction. REFERENCES • Anton RF, Latham P, Voronin K, Book S, Hoffman M, Prisciandaro J, Bristol E. Efficacy of Gabapentin for the Treatment of Alcohol Use Disorder in Patients with Alcohol Withdrawal Symptoms: A Randomized Clinical Trial. JAMA Intern Med. 2020;180(5):728-736. • Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011;168(7):709-717. • Blodgett JC, Del Re AC, Maisel NC, Finney JW. A meta-analysis of topiramate’s effects for individuals with alcohol use disorders. Alcohol Clin Exp Res. 2014;38(6):1481. Epub 2014 May 5. • Camchong, Jazmin, Victor Andrew Stenger, and George Fein. 2013. “Resting-State Synchrony in Short-Term versus Long-Term Abstinent Alcoholics.” Alcoholism, Clinical and Experimental Research 37 (5): 794–803. • Cheng YC, Huang YC, Huang WL. Gabapentinoids for treatment of alcohol use disorder: A systematic review and meta-analysis. Hum Psychopharmacol. 2020;35(6):1-11. • Combined analysis of the moderating effect of a GRIK1 polymorphism on the effects of topiramate for treating alcohol use disorder. Henry R. Kranzler, Emily E. Hartwell, Richard Feinn, Timothy Pond, Katie Witkiewitz, Joel Gelernter, Richard C. Crist. Drug and Alcohol Dependence 225 (2021). 108762. • Dupouy J, Palmaro A, Fatseas M, et al. Mortality Associated with Time in and out of Buprenorphine Treatment in French Office-Based General Practice: A 7-Year Cohort Study. Ann Fam Med 2017; 15:355–358. [PubMed: 28694272]. • Florez, G., Saiz PA, Garcia-Portilla P, Alvarez S, Nogueiras L, Bobes J., et al., Topiramate for the treatment of alcohol dependence: comparison with naltrexone. Eur Addict Res, 2011. 17(1): p. 29–36. • Hägg S, Jönsson AK, Ahlner J. Current Evidence on Abuse and Misuse of Gabapentinoids. Drug Saf. 2020;43(12):1235-1254. • Jonas DE, Amick HR, Feltner C, Bobashev G, Thomas K, Wines R, Kim MM, Shanahan E, Gass CE, Rowe CJ. • Garbutt JC. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May;311(18):1889-900. • Mason BJ, Quello S, Shadan F. Gabapentin for the treatment of alcohol use disorder. Expert Opin Investig Drugs. 2018;27(1):113-124.
Summer 2022
15
Tackling Substance Use Disorder
Learning to Love Through Addiction and Loss
I
learned of my dad’s death after my first organic chemistry class. It was the first day of my sophomore year of college. He died at home suddenly. His autopsy revealed he likely had a heart attack while experiencing an alcohol withdrawal seizure. Despite being intimately familiar with the impacts of addiction, I didn’t know that what he struggled with was a disease. At the time, I felt alone and ashamed because of what was happening to him and our family. It wasn’t until four years later — while sitting among patients at the Betty Ford Center in Rancho Mirage, Calif., as a medical student and summer intern — that I began to learn more about addiction and experience the healing power of connection. When I started studying at the University of Minnesota Medical School, I was still hiding all of my feelings and emotions related to my dad’s disease and death. I now know this is a common reaction to trauma and loss, which contributes to isolation and shame. Many families like mine cope in this way due to the stigma associated with substance use disorders and mental illness. We put our heads down and pretend like nothing happened. As I began my experience at the Betty Ford Center’s Summer Institute for Medical Students, immersed in treatment with patients and their clinicians, I was unsure if or how I would tell anyone about my dad. But as soon as I was asked to participate in a recovery group with a small cohort
By Sara Polley, MD
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Summer 2022
of patients. I introduced myself as a medical student, paused, and quickly shared — for the first time anywhere — that my dad had died of alcoholism. It was a profound beginning to my personal journey of healing and sparked a newfound purpose that would guide my professional pursuits. Throughout my immersive educational experience, I was flooded with emotions. I felt excitement meeting patients and professionals who openly spoke about their stories of pain, loss, and recovery. And I felt peace beginning to understand that my dad died because he had a disease — a disease like other diseases, worthy of medical care and compassion. The truth that I had felt was validated: my dad did not choose alcohol instead of me, he was compelled to the choice by his illness. He fought as best he could, until he couldn’t anymore, and I am lovable precisely because of my experience as his daughter and not in spite of it, as I had feared. His addiction was a terminal illness, as it had been for his father, and as it is — sadly — for many people across the world. For the first time, I was able to feel proud and connected to my family. This also created the opportunity to boldly connect my identity with my drive to become a physician. Fifteen years after experiencing the Summer Institute for Medical Students, I had the good fortune in 2021 of joining the Hazelden Betty Ford Foundation as a psychiatrist and medical director. Now, I
get to help the next generation of doctors and share my passion for creating a society where all those impacted by addiction and mental illness can feel the love and connection I felt. I want all those suffering to feel belonging, pride, and a sense of resilience — especially those who are sickest and at risk of dying. Everyone, regardless of their current state of health, deserves to feel cared for and worthy. I implore those of us in health care to embrace patients experiencing substance use concerns by interacting with love, compassion, and acceptance. This vulnerability and tolerance can be hard. Not only does it require us to consider our own fears and biases, but to acknowledge our lack of familiarity and competence. We did not get enough education on addiction and recovery during our medical training. According to the National Survey on Drug Use and Health, medical students
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only receive two to 10 hours of education about addiction even though this disease strikes one in 10 Americans over age 12 (Substance Abuse and Mental Health Services Administration, 2013). Instead, we are exposed most often to kindhearted physician mentors’ expressing frustration and fear while trying to avoid people who have substance use disorders — a reaction that makes sense in context. When we aren’t given the tools to care for people and are asked to do it anyway, it is burdensome and overwhelming. Unfortunately, to overcome this burden, we must act to educate ourselves. I encourage all physicians to learn how to screen for mental health and substance use disorders in your patient population. Practice brief intervention skills and tolerance. Find ways to refer patients to treatment. Accept that addiction is a chronic, relapsing and remitting condition for many — a disease process located in the brain that alters behavior and motivation. Come to understand that difficulties in illness
management are the fault of the disease, not the individual. One of the most valuable skills I’ve learned from patients is letting go of my agenda for their lives. I communicate my boundaries and am transparent with my thought process when making a recommendation. Above all, I ask for permission to help, and try to model acceptance, love, and hope. Moving into my new office at Hazelden Betty Ford in Plymouth, Minn., I unpacked my copy of the Alcoholics Anonymous “Big Book” I had received during my medical school experience at the Betty Ford Center 15 years ago. Before placing it on the shelf, I re-read notes from patients I had met that summer. My favorite was written by a mother with grown children. It says: “I will never forget the experience we had together. It was a blessing. I can see now how my illness looks through my daughter’s eyes. This will motivate me in my recovery. Your dad loves you. I will be thinking about you and I know you will
P E A C E
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be a good doctor.” I’d like to think my father was speaking through her that day. Dad, I love you, too. Sara Polley, MD, is the medical director at the Hazelden Betty Ford Foundation’s national substance use and mental health treatment center for adolescents and young adults in Plymouth, Minnesota. Dr. Polley is board-certified in Adult Psychiatry, Child and Adolescent Psychiatry, and Addiction Medicine. She completed her Child and Adolescent Psychiatry fellowship at Boston Children’s Hospital, and was chief fellow during her final year there working with the Pediatric Addiction team on research-based interventions that integrate medical, psychological, spiritual, and social treatments for both individuals and families. Prior to that experience, Dr. Polley completed her Adult Psychiatry training in a joint program between Sheppard Pratt Hospital and the University of Maryland. She is a graduate of the University of Minnesota Medical School.
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Summer 2022
17
Tackling Substance Use Disorder
Why Prescribing Suboxone Has Enriched My Practice
I
wear a lot of hats in my current practice: working in the hospital and clinic, teaching medical students and residents, seeing patients, mentoring, and so on. Generally though, what makes my day better is the same in all these roles. My satisfaction comes through forming relationships and making a difference. What does this have to do with prescribing Suboxone (buprenorphine/naloxone)? It has enhanced clinic work in these same ways — forming relationships and making a difference. Physicians, including myself, often are hesitant to start working with patients with addiction/substance use disorder. The worry is often about two things: First is increased conflict and drama. I worried that I would feel the way I sometimes do with patients requesting opioids. There can be intense confrontations and patients making threats and/ or storming off. Second, I also worried, as I do with opioid prescribing, that I would end up hurting patients — that patients would misuse the medication and end up overdosing. I have been lucky to have a friend who is a strong advocate for Addiction Medicine and a helpful mentor, Dr. Bob Levy. I started my Medication-Assisted Therapy journey while I was working with him part-time at Broadway Family Medicine. He asked me to take a course and become certified. Broadway was making this a requirement at the
By Javad Keyhani, MD
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Summer 2022
time. He said that you can’t opt out of hypertension management as a family physician, why should you be able to opt out of managing patients with substance use disorder? He also told me he would be there to support me through this transition and answer questions and concerns that came up. I took a course and became certified. Soon, I switched over to Smiley’s Family Medicine Clinic where I was one of only a few doctors who were prescribing Suboxone — Suboxone is the brand name of buprenorphine/naloxone and is one of several buprenorphine products that are available. I learned more from Dr. Levy and actually working with patients than I did with the course. I learned that it was often better to have patients take at least a moderate dose of Suboxone. With other opioids, like Oxycodone, a lower dose means less risk. But Suboxone is stickier (higher affinity) but has less potency. So, a moderate to high dose is more protective since it will prevent
overdose if the patient relapses and takes other opioids. The hardest early lesson was how to initiate Suboxone. With its high affinity it will displace other opioids. The patient needs to already be in significant withdrawal when you start it or it can put them into immediate severe withdrawal. Most patients know this though and many have already used Suboxone in the past, either prescribed or bought outside the clinic, so this is less of an issue. There are also micro-dosing techniques. There is a learning curve, but it wasn’t as steep as I thought. But what I really want to tell you about is how it has improved my practice. One of the best pieces of advice I received from Dr. Levy was to mentally substitute “diabetes” for “substance use disorder.” We have been taught to think of addiction as a chronic illness and putting it into practice takes some getting used to — but it is helpful. For instance, when a patient with diabetes has a sudden rise in their A1C, we ask them what is happening in their life that might have contributed to this. Sometimes it is that they have been missing medication doses, or eating more sweets or lost their housing and can no longer refrigerate their insulin. Similarly, when a patient taking Suboxone has a urine drug screen that shows opioids, I start by asking what has happened. Sometimes patients will deny a relapse. But often, if asked without judgment, they will tell me what is happening in their life that led to the relapse. With a patient with diabetes, we will problem solve together
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and often see them back for follow-up sooner. This is the same way we treat our patients with substance use disorder. The first step is to intensify treatment. I may ask them to come back in a week or two rather than a month. In the same vein, as I would hospitalize my patients with diabetic crises, I may suggest formal outpatient or inpatient treatment for patients with substance use disorder. Just like with any chronic disease, it helps to have a whole team helping a patient and a customized care plan. One of the great things about Medication-Assisted Treatment is that the medication is pretty straightforward — just one medication. With diabetes, I may spend the whole visit adjusting medicines. With substance use disorder, we can talk about
their home life, their goals, support system (including NA), and mental and physical well-being. These are satisfying visits where I can connect to patients over time. These push me as a provider in similar ways to how parenting has pushed me. I work to always treat the patient with respect while holding them accountable for their actions. I try to bring conversations back to goals and values and patients decide what they are willing and able to commit to. This is satisfying and valuable work. Why should you consider learning Medication-Assisted Treatment? Like any area of medicine, this work can have its challenges. Some patients are very high-risk, or aren’t able to participate in our program, and need to be referred to
an addiction program. But studies have shown that patients often are more satisfied and have similar outcomes when treated by their primary care physician. And there is a huge need. Over 600 Minnesotans had opioid-involved deaths last year. We now train all our residents Medication-Assisted Treatment. In our pandemic world, patients are struggling and doctors are burning out. It may seem overwhelming to take on a new area of practice. But for me, prescribing Suboxone has been a win-win for my patients and me, and has enriched my practice. Javad Keyhani, MD, Assistant Professor of Family Medicine – UMMC/Smiley’s RPAP/MetroPAP Faculty University of Minnesota.
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Summer 2022
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Tackling Substance Use Disorder
Behavioral Health Integration: Why Minnesota Needs to Keep Going Ask just about anyone. Minnesota was once known as an innovator in integrating behavioral health in primary care, particularly depression care, and then — some of the wind left the sails. While some examples of integration exist, it is not yet common. Why hasn’t there been more focus on making this change? We urge you to read the full Institute for Clinical Systems Improvement (ICSI) report (https://bit.ly/ICSIreport) on the issue, one of the last bodies of work before ICSI closed, created by a community of healthcare leaders working together. Here we provide commentary and newly released reports that further emphasize why Minnesota needs to re-focus on behavioral health integration. We Need More Doors
It is not remotely possible to meet the demand for mental health and substance use disorder care by doing more of what we have been doing. Integration in primary care settings both optimizes the precious behavioral health professionals we have, and it allows patients to receive care in a setting they prefer: their primary care clinic. A 2020 systematic review indicates that providing behavioral health care in primary care is particularly important for Black, Indigenous, and People of Color (BIPOC) as compared to care as usual, while one study of veterans shows promise for men, who generally are less likely to engage in mental health and substance use disorder (SUD) care.1 In addition, we’ve long known that By Paul Goering, MD, Tani Hemmila, MS and Claire Neely, MD
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Paul Goering, MD
Tani Hemmila, MS
the majority of people who complete suicide have been seen in primary care in the year before.2 Leveraging the relationship between a patient and their primary care physician (PCP) in a patient’s moment of need might literally be a once in a lifetime opportunity. Models like the Collaborative Care Model (CoCM) (https://bit.ly/CoCM21) support primary care to ensure that the PCP has a behavioral health team behind them to address patient’s behavioral health needs — needs that already show up in their primary care visits, and that compromise the rest of health.3 The CoCM model is based on principles of care for chronic conditions, focusing on treating to target by tracking populations in a registry. PCPs and embedded behavioral healthcare managers provide medication adjustments and psychosocial treatment with psychiatric case consultation as needed. It is important to note that behavioral health integration does not supplant the need for mental health or substance use disorder providers in community organizations, large systems, or private practice.
Claire Neely, MD
These services will always be needed. Instead, integration in primary care provides a door for people who look to their own primary care team for guidance. It reaches many of the population who do not otherwise seek behavioral health care, circumventing full-blown crisis and emergency department visits. We Need Redesigned Structures
Integration challenges long-existing structures that separate mental health care and substance use care from other medical care. Most organizations continue to work around these siloed structures instead of redesigning them to suit both patients and the future of health care: value-based payment for whole person care. Repeatedly, we have seen promising integration efforts disintegrate because of structural challenges. Behavioral health and medical health care are managed by leaders in different operational units and creates operational challenges such as: Who hires and pays for the care coordinator? How is their schedule managed? Macro systems also need restructuring.
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In 2017 the Centers for Medicare & Medicaid Services (CMS) instituted CoCM codes (following Behavioral Health Integration codes), providing payment for non-visit time needed to coordinate care and consult in primary care. In Minnesota, commercial plans now cover the CoCM codes, and as of this writing our state Medicaid office is working on it. We Need to Follow the Evidence
The Collaborative Care Model has become, deservedly, the gold standard for integrated behavioral health. CoCM is built upon patient-centered measurement and treatment to target pathways, including relentless treatment intensification when patients are not getting the outcomes they need. Outcome measurement is also critical for care systems and payers, to learn what structural changes are working and where more attention is needed. Many organizations start integration efforts with a co-located model, or other methods of integration. Organizations who choose integration models other than CoCM must carefully monitor outcomes selecting metrics that are the same as for CoCM.
showing a decrease in depression symptoms.1 A large new study further adds to the literature that CoCM supports improved access and outcomes for BIPOC populations receiving CoCM care vs. usual care.5 That same study, however, also had less engagement by BIPOC in CoCM than by white patients, indicating that targeted CoCM modifications may be beneficial. And, while telehealth in integrative care/ CoCM has become a preferred method of care generally (see this new report by the American Medical Association https://bit. ly/AMAreport21) it shows specific promise for BIPOC individuals when combined with the Collaborative Care Model.1 In Summary
It is critical that we step up our efforts to redesign the continuum of services to meet people’s behavioral health needs. As health care moves further into a value-based care and payment world, integration will help get us there. And COVID has proven that while changing clinical, operational, and financial structures is daunting, we can do it.
We Must Serve All People
The first integration effort in Minnesota, DIAMOND (Depression Improvement Across Minnesota Offering a New Direction), was for adult depression only. Now, organizations across the nation are implementing CoCM across age groups and for other psychiatric needs such as anxiety and bipolar — again with more acute and severe needs being triaged to specialty care. In Minnesota, more organizations need to follow this emerging evidence. Growing evidence demonstrates integration’s effectiveness in meeting substance use disorder (SUD) needs in a primary care setting.4 The number of people at risk of SUD has skyrocketed during the pandemic, and integration models provide primary care with support to meet these needs effectively and with confidence. Finally, systematic review shows potential for CoCM in improving depression among BIPOC and that outcomes can be sustainable, with eight of 12 studies MetroDoctors
The Journal of the Twin Cities Medical Society
An old Chinese proverb states: “When is the best time to plant a tree? 20 years ago. When is the second-best time? Today.” Minnesota health care is often a national front-runner. In the case of behavioral health integration in primary care, now is the second-best time. Paul Goering, MD is a psychiatrist, physician leader, former healthcare executive and advisor for multiple behavioral healthcare innovation organizations and efforts. Tani Hemmila, MS, a Managing Principal with Health Management Associates and former Director of the MN Health Collaborative at ICSI, works on behavioral health systems redesign locally and nationally. Claire Neely, MD, past President and CEO for ICSI, is known for her expertise in managing, influencing, and driving continuous quality improvement in health care and is currently consulting on several statewide projects. References available upon request.
Do your patients have trouble using the phone due to a hearing loss, speech or physical disability? The Telephone Equipment Distribution Program offers easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Web: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.
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The State of Minnesota’s Medical Cannabis Program
I
n the United States, the use of cannabis for medical purposes has been approved in 37 states, with California being the first to approve a state medical cannabis program in 1996. Minnesota’s Medical Cannabis Program was approved in 2014 and launched in 2015. Early enrollment in Minnesota’s program was lower than expected, and some patients had difficulty finding a healthcare practitioner who would certify them for the program. As of May 5, 2022, however, the program had more than 34,500 active patients. With more than 2,100 participating healthcare practitioners, patients now have more access to practitioners to certify them than ever before. The program has matured and expanded in other ways, while staying grounded in a guiding principle to learn from the experience of its patients and participating healthcare providers. How is that accomplished? Among the ways, the Office of Medical Cannabis (OMC) publishes reports based on observational studies from patient-reported data and opinion surveys of medical cannabis patients and their certifying healthcare practitioner. The goals of this article are to provide an update on the state’s Medical Cannabis Program and to encourage members of the medical community to learn more about the program. Highlights of Recent Changes
Qualifying medical conditions When the Minnesota Legislature authorized the creation of the state’s Medical Cannabis Program, the law included nine By Nicholas Lehnertz, MD, MPH, MHS and Chris Tholkes, MA
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medical conditions that qualified a patient to receive medical cannabis. Since then, the list of qualifying conditions has grown to 17, with sickle cell disease and chronic motor or vocal tic disorder being added in 2021. Every year, members of the public can request the Commissioner of Health to add a qualifying medical condition during OMC’s petition process in June and July.
Nicholas Lehnertz, MD, MPH, MHS
Introduction of dried flower, infused edibles In 2021, state lawmakers approved smokable cannabis as a new delivery method. OMC developed new rules for the addition of dried flower, which became available for registered patients 21 years old and older starting March 1, 2022. MDH expects patient enrollment to double or triple, based on the experiences of other states that added dried flower to their medical cannabis program. As part of the launch of dried flower, OMC provided messaging to patients on the risks of smoking, including those related to secondhand smoke and lung health. The introduction of dried flower will mean more access to patients who cannot afford other forms of medicine currently being offered. Prices of dried flower are expected to be lower than other products because it bypasses normal processing used to make other medicines. Infused edibles (in the form of gummies and chews) will become a new delivery method in the program effective Aug. 1, 2022. A request for this delivery method was submitted and approved through
Chris Tholkes, MA
MDH’s annual petition and comment process. OMC plans a rulemaking process covering packaging, testing, and other patient safety protections related to infused edibles. New dispensaries open Growth in the program also means that patients have more options of getting their medicine closer to home. State law now allows Minnesota’s two medical cannabis manufacturers to each operate up to eight dispensaries, double the amount the legislature originally authorized when medical cannabis was first legalized. Green Goods operates dispensaries in Blaine, Bloomington, Burnsville, Hermantown, Minneapolis, Moorhead, Rochester, and Woodbury. LeafLine Labs operates dispensaries in Eagan, Hibbing, Mankato, St. Cloud, St. Paul, and Willmar. Healthcare Practitioner Satisfaction Levels
In 2021, OMC released findings of a first-ever satisfaction survey of healthcare practitioners who participate in the Medical Cannabis Program. Overall, the
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majority (85%) of survey respondents were very satisfied or somewhat satisfied with the program. Among the survey results: • 46.2% of the survey respondents learned about the Minnesota Medical Cannabis Program from a colleague. • 94.4% found the process to register as a healthcare practitioner who can certify patients very easy or somewhat easy. • 73.1% rated Continuing Medical Education courses about medical cannabis as the most useful resource among several listed. • 78.9% rated increased communication among pharmacists, providers, and patients as a somewhat important or very important program improvement. • 38.6% said that practitioners should be allowed to use telemedicine to certify patients, including the patient’s initial visit to get certified. • 63.1% said they did not want to be on a public list of practitioners who certify patients. The survey was emailed to 1,894 healthcare practitioners who are registered with the program. The data collection period closed after two months, with 252 completed surveys.
Comprehensive reports are produced for annual cohorts of enrolled patients and for the first five months of patients who are enrolled for new qualifying conditions. Among the results for patients certified for intractable pain, for instance, practitioners reported on how medical cannabis treatment resulted in reducing dosage or eliminating medications used for pain. For patients with first enrollment between July 2015 and June 2017, of the 1,166 MDH survey responses for intractable pain patients, nearly 60% of the practitioners reported a reduction of pain medications for their patients, with 382 surveys (33%) indicating a decrease in opioid medication. Some patients were able to eliminate opioid use altogether. Healthcare practitioners are encouraged to review OMC’s website for more resources (www.health.state.mn.us/medicalcannabis). Among them, OMC publishes condition-specific reports and data dashboards — new reports are planned for autism and obstructive sleep apnea. OMC also collaborates with external partners on research using data from the Medical Cannabis Program Registry, which adds to the scientific literature. Researchers who are interested in collaborating should contact OMC for more information.
Learning From the Experience of Patients
Looking Ahead
Minnesota’s Medical Cannabis Program is unique among other programs in the U.S. in that it is committed to learning from the experience of the participants. Data is available from three main sources: patient enrollment/re-enrollment, surveys of patients and healthcare practitioners, and patient self-report data at the time of each purchase of medical cannabis. The patient self-report data includes scale responses for a set of eight symptoms (for example, pain, nausea, and anxiety), current medications, medical conditions, as well as medical cannabis benefits and side effects. MetroDoctors
Discussions about legalizing adult recreational use of cannabis continue at both the state and federal levels. Minnesota Gov. Tim Walz’s 2022 budget proposal recommended legalization of cannabis for adults. While the prospect of passing legalizing adult recreational use in Minnesota remains to be determined, public health has been part of the conversation. The Governor’s proposal included funding for youth cannabis use prevention, education for pregnant and breastfeeding women about the health effects of cannabis use, data collection on cannabis use in Minnesota, and new testing standards for
The Journal of the Twin Cities Medical Society
contaminants found in cannabis products. The state of Minnesota’s Medical Cannabis Program is strong, and the number of healthcare practitioners who certify patients continues to grow. Healthcare practitioners and representatives from clinics and health systems interested in learning more about the program can request a presentation from OMC staff by going to www.health.state.mn.us/speakerrequest. Nicholas Lehnertz, MD, MPH, MHS, is a medical specialist in Infectious Disease Epidemiology, Prevention and Control at the Minnesota State Department of Health. He received his medical degree from the University of Minnesota, his residency training at the University of Vermont and Johns Hopkins Medical Institutions, and his public health training at Johns Hopkins School of Public Health. Prior to joining MDH, he provided direct patient care to members of the White Earth Reservation in northwestern Minnesota. In total, he has worked in over 15 different countries with organizations such as the CDC, WHO, Population Services International, and the International Rescue Committee on Zika response, HIV, malaria, diarrheal diseases and maternal and child mortality. Email: nick.lehnertz@state.mn.us. Chris Tholkes, MA, brings more than 25 years of experience working in the public, nonprofit, and philanthropic sectors. She is Director for the Office of Medical Cannabis at the Minnesota Department of Health and sits on the board of directors for the Cannabis Regulators Association. Previously, she served as Assistant Division Director for the Office of Statewide Health Improvement Initiatives, which includes the Statewide Health Improvement Partnership (SHIP), Tobacco Use Prevention Grants and Tribal Grants. She holds a bachelors in community health education from Minnesota State Moorhead and a Masters in Public Administration from Hamline University. Email: chris.tholkes@ state.mn.us.
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Historic Win for Minnesota in Saint Paul: Tobacco Control Policy Achieved Through Community Advocacy
No more price incentives to buy cigarettes, fewer tobacco retailers, no more menthol cigarettes in liquor stores, and less tobacco advertising: no small accomplishment for a local tobacco ordinance, but that is what Saint Paul did with their tobacco ordinance last November. Supported by a broad coalition of health advocates and youth, the Saint Paul City Council voted unanimously to adopt the most comprehensive tobacco regulation in the country. The ordinance: • Prohibits the redemption of coupons and discounts for all commercial tobacco products, including e-cigarettes. • Sets a minimum price for cigarettes and chewing tobacco, meaning that these products cannot be sold for less than $10 in the city of Saint Paul. • Increases penalties for retailers who sell commercial tobacco products to people under 21, or who violate the city’s restrictions on the sale of flavored tobacco. This ordinance is the first of its kind in the nation in its scope and sets an example for other communities in Minnesota and across the U.S. for what is possible in tobacco prevention. Tobacco price discounting is a problem because the tobacco industry uses coupons and heavily targeted marketing to lure in new customers and keep long-time customers coming back for more. Research shows that young adult non-smokers in By Kate Feuling Porter, MPH and Jeanne Weigum, MSW
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Minnesota are twice as likely to start smoking if they receive coupons, and of adults who do smoke — one third use coupons/discounts each time they receive one. The tobacco industry specifically targets young people Kate Feuling Porter, MPH Jeanne Weigum, MSW and low-income Minnesotans with price discounting, and over video, and do a photo shoot so that all all these communities are among those campaign materials would look like and with the highest use rates of commercial represent Saint Paulites. tobacco. COVID-19 disrupted the campaign Coalition-building and maintenance in Saint Paul when it hit in 2020. By then is an essential part of grassroots organizing advocates had been working on the issue and advocacy. To pass Saint Paul’s price for roughly a year, and policy passage was discounting ordinance, a strong coalition in sight. COVID-19 meant advocates of advocates organized and effectively lobhad to find alternate ways to educate and bied for this policy for nearly three years. organize in a world without communiAdvocates, supported by the Association ty gatherings and events. Advocates also of Nonsmokers – Minnesota (ANSR), inrecognized that spring 2020 was not the cluded health groups such as Twin Cities time to push this issue at City Hall as the Medical Society and community partners council was overwhelmed with pandemic representing youth and the diverse popuresponse and later with community unrest lations that make up Saint Paul. following the murder of George Floyd. Early in the campaign ANSR staff and Advocates pivoted to education, adapting partners conducted key informant interto Zoom, giving multiple presentations to views to do message testing. Themes soon different District Councils and communiemerged and it became clear that people ty groups to gain support for the policy. often bought things they did not want or Council President Amy Brendmoen need because the price was too good to pass referred ANSR to a youth leadership up. When the “thing” being discounted is group in Saint Paul. The youth took on a commercial tobacco product, the issue at the issue and helped with educational prehand becomes a life-threatening addiction. sentations, participated in meetings with After several months of message testing, councilmembers and sent letters of supANSR hired a local agency to design the port to the council. In more normal times campaign creative, create a promotional youth would have helped at community MetroDoctors
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events, tabling, and other types of outreach but they adapted to the new remote way of doing things and became impactful advocates. Organizing during a pandemic didn’t look much like any organizing before 2020 but it was still effective. One crucial aspect of passing any policy is understanding the opposition. In local policy, there is often the opportunity to read letters submitted to the council on either side of the issue. Advocates pored over letters from retailers and the tobacco industry and developed talking points based on the opposition’s arguments. This kind of strategy empowers advocates and community to clarify and provide accurate information to elected officials. The policy passed with full support from the council and was implemented in December 2021. ANSR staff and partners did a pre- and post-implementation assessment of 137 tobacco retailers in Saint Paul. The policy proved effective and nearly all vendors complied with it. Three months after the effective date, only two retailers sold cigarettes or chew for under the
minimum price of $10, and no stores accepted coupons. A positive unintended consequence is that almost all external tobacco advertising has disappeared from storefronts. With almost 100% compliance immediately after implementation, it is clear that this policy is powerful and years of advocacy are already paying off. Other communities now have a powerful policy to point to, with tried-and-true effective methods of organizing and advocacy. There are organizations, like ANSR, that help provide education and other support. Organizations like Twin Cities Medical Society work closely with partners to follow policy progress and engage physician advocates in advocacy, from writing an email to their city council to testifying at a public hearing. When it comes to price discounting specifically, other cities should be encouraged by the success of this campaign, and the broad support for it. While this campaign took over three years from start to finish, it exemplified a pillar of true community organizing and advocacy: to achieve policy that is truly
When the “thing” being discounted is a commercial tobacco product, the issue at hand becomes a life-threatening addiction. equitable, it is essential to get it done right, with community, rather than to get it done fast. Kate Feuling Porter, MPH (she/her/hers), Senior Program Manager, Twin Cities Medical Society. Email: kfeuling@metrodoctors.com; Phone: 612-710-8225. Jeanne Weigum, MSW, President, Association of Nonsmokers – Minnesota (ANSR). Email: jw@ansrmn.org; Phone: 651-646-3005.
For pregnancy, ChooseYourFish.org helps me give advice quickly and with confidence.
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Tackling Substance Use Disorder
Environmental Health Fossil Fuel Addiction Affects Us All
T
he insidious process of addiction begins with the use of substances that cause harm to human health. Let’s take it to a different level and consider fossil fuels as such a substance. In his State of the Union address on Feb 1, 2006, President George W. Bush warned the U.S. that it must break its “addiction” to oil. We all participated in fossil fuel addiction because we wanted warm homes and buildings. We wanted public and private mobility. With fossil fuels we gained widespread advances in industry and technology. This began the era of success and growth in the world, but it hid the degree of danger that fossil fuel addiction posed. Blinded by money and a false sense of pride and power over our planet, we joined together as addicted societies. We framed our laws and policies to embrace and encourage the fossil fuel addiction. Once any addiction pervasively spreads through a society, incredible sums of money are earned by the companies who produce the substance. When it becomes evident, as it now has, how harmful the addiction truly is, the harm to human health inflicted by the substance is often denied by the companies who are profiting from the addiction. The denial takes insidious forms. Rather than taking responsibility for the devastating consequences to human health, companies spend huge sums of money on “fake” research to disprove or discredit the health impact. They spend
By Mike Menzel, MD and David Hunter, MD
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even more on false ads that attempt to delegitimize the scientists and the research that proves the connection between the substance and harm to human health. These tactics are the foundation of the denial playbook.1 The longer this process of denial continues the longer the money continues to roll into the companies. The real question for healthcare professionals is how can we help our society and leaders to develop a plan for recovery from fossil fuel addiction. Most importantly, health professionals should recognize and clarify the impacts that climate change has on the health of our patients. Depending on the geographic location of the patient population we may see increases in Lyme disease, heatstroke, mental illness from climate anxiety, and lung and cardiac disease from industrial air pollution, wildfire smoke and transportation exhaust. Unfortunately, all these illnesses are subtle and diffuse. Therefore, where the trends and problems are clear, we need to be powerful advocates for truth and change. We must also bring attention to those disadvantaged groups for whom the problems are almost universally worse, but who are often ignored. These groups include the elderly, the very young, and BIPOC communities who frequently have no public voice or standing. Equally important, health professionals can also advocate for social structural solutions that will benefit everyone. We can demand that our local, state, and federal leaders enact laws and policies that will allow society to make choices that will accelerate the clean energy transition. Some leaders have already started the process
of mitigation and rehabilitation, but the pace needs to accelerate to obtain a fossil fuel free society by 2050. As all of us break free of our addiction, it will offer us greater geopolitical, economic, and climatic stability. Furthermore, we as health professionals can take steps to make our healthcare systems fossil fuel free. We can advocate for divestment of fossil fuel companies in the financial portfolios of healthcare institutions, health insurance companies and large hospital systems. As with any addiction, community engagement is key to remaining substance free. Our role as healthcare providers is a critical component of each and every community. We are a trusted resource and can improve the well-being and health of our patients. We should develop creative ways to educate our patients not only about reducing carbon emissions in their homes and communities, but also what steps we all need to take to have healthier and more sustainable lifestyles.2 We can give our communities hope for a renewable economically secure society that offers us a brighter future in which our families can not only survive but also thrive. References: 1. A Major Deception on Global Warming, Wall Street Journal, June 12, 1996. 2. www.projectdrawdown.org: a science-backed, data-driven list for climate change solutions that can guide you.
Mike Menzel, MD, member, TCMS and Health Professionals for a Healthy Climate. David Hunter, MD, Professor Emeritus, Interventional Radiology, University of Minnesota.
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Gregory J. Beilman, MD Receives the 2021 Charles Bolles Bolles-Rogers Award Gregory J. Beilman, MD, Senior Vice President of Acute Operations for the Minnesota Health Fairview Health System, received the 2021 Charles Bolles Bolles-Rogers Award from the Twin Cities Medical Society Foundation (TCMSF). TCMSF Board member David Hamlar, MD, DDS presented the award during a special event held on the M Health Fairview Riverside campus. Candidates for this “Physician of Excellence” award must be considered to be an outstanding physician by their peers. Candidates are nominated by their colleagues at Twin City area hospitals and/or clinics for achievement or leadership in medicine, contributions to clinical care, teaching and/ or research. Dr. Beilman serves as Senior Vice President of Acute Operations for the Minnesota Health Fairview Health System and is the Owen H. and Sarah Davidson Wangensteen Chair of Surgical Research at the University of Minnesota. He has an active translational research program funded by the Department of Defense, other federal institutions, and industry with the major thrust of this program being evaluation of the metabolic response to hemorrhagic shock and injury. In addition, he has worked for nearly two decades in the area of severe acute and chronic pancreatitis and surgical therapy for these conditions. Beilman is a retired Colonel in the Army Reserves and has deployed five times, serving during a recent deployment as the CENTCOM Joint Theater Trauma Director in Iraq and Afghanistan. He has significant experience in global health efforts, with his experience in the Army and decade of patient care and research efforts in Uganda. Beilman completed medical school at the University of Kansas in Kansas City and surgery residency at the University of Kansas in Wichita. He and his wife moved to Minnesota to complete additional training (Surgical Critical Care fellowship) and subsequently spent his post-fellowship career in Minnesota. Comments from Beilman’s colleagues
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reflected on his additional accomplishment of leading the efforts at M Health Fairview to establish a COVID response effort transforming Bethesda, and then St. Joseph’s hospitals into a statewide triage system for critical care. “His leadership ability, developed by a lifetime of service, including serving in the military, was instrumental in the program’s success.” Charles Bolles Bolles-Rogers (18801971), for whom the award is named, was a well-respected Minneapolis resident who served for many years on the (former) St. Barnabas Hospital Board of Trustees. In addition, Bolles Bolles-Rogers worked tirelessly throughout his life to further the interests of the health and hospital needs of the city. The Twin Cities Medical Society Foundation is honored to present the 2021
The Journal of the Twin Cities Medical Society
Charles Bolles Bolles-Rogers Physician of Excellence Award to Gregory J. Beilman, MD. See 2022 Nomination Information on page 11.
TCMS Foundation Board Representative David Hamlar, MD, DDS (L), presented the Charles Bolles Bolles-Rogers Award to Gregory Beilman, MD on March 2, 2022.
CAREER OPPORTUNITIES
Lakeview Clinic has what you are looking for! Join an independent, physicianowned group of 50 providers in the SW Metro. Be a part of a collaborative work environment in a primary care group of family physicians, internists, pediatricians, general surgeons and OB/GYNs. • 4-day work week with 32 contact hours achieving excellent work/life balance • Excellent compensation with a 2-year partnership track to earn in the top 10% in the state • Outstanding benefits including 100% paid family health insurance and dental insurance, 401K and profit sharing • We have 4 sites in the southwest metro: Chaska, Waconia, Norwood, and Watertown
Due to retirements and growth, we are currently looking for: ◦ Internal Medicine ◦ Family Medicine ◦ Pediatrics
CONTACT: administration@lakeviewclinic.com PHONE: 952-442-4461 ext. 7215 WEB: www.lakeviewclinic.com
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FUTURE
Physician Leaders By Elizabeth Babkin (MS4) and Thomas Marcroft (MS4)
Education in Addiction Medicine: Progress, Not Perfection When entering medical school, our path begins with a commitment to serving our patients. We often learn quickly that the circumstances of a patient’s life are just as important as their diagnoses. Nearly all medical students have seen addiction and its impacts on ourselves, our loved ones, and our communities. As the discussion around the complexities of these narratives unfold around us, the question of our role as future physicians invariably arises. Upon entering medical school in the Fall of 2019, the issues and practices of addiction medicine in the University of Minnesota curriculum were somewhat thin. References to substance use disorders were typically limited to a quick mention at the top of a question stem (“A 56 y.o. man with opiate use disorder…”) or listed in passing as a risk factor when discussing major illnesses. When expanded upon, discussion was often brief. A class session in our first semester, for example, provided an opportunity for students to meet in small groups with an individual working toward recovery. This session was a favorite for many in our class but, when months went by with little follow-up, it left many wondering why more content like this wasn’t built into our curriculum. If these issues were so prevalent, where were our tools to manage them? It was from this question that our class formed the Addiction Medicine Interest Group in the spring of 2020. Our aim was to advocate for an expansion of the curriculum to include more information about addiction medicine, particularly more diverse stories as well as introducing content experts in expanded dialogues. This proved to be incredibly popular. When our first Naloxone training was offered as an optional session, registration for the session filled in less than six hours. Even as learning was forced online due to the COVID-19 pandemic, virtual sessions on topics such as methadone/buprenorphine assisted therapies and harm reduction efforts such as needle exchanges remained heavily attended by both students and staff. In response to the overwhelming enthusiasm for this type of programming, the Medical School incorporated training in rescue naloxone and harm reduction perspectives into our 3rd and 4th year 28
Summer 2022
Elizabeth Babkin (MS4)
Thomas Marcroft (MS4)
“Becoming A Doctor” curriculum. Students were not only able to receive Narcan training from both a Steve Rummler Hope Network representative and an addiction medicine doctor, but had a round table with professionals working in all aspects of harm reduction which allowed us to expand our knowledge base and ask questions about the current strides and challenges of addressing this problem in Minnesota. It proved to be incredibly beneficial with many citing it as their favorite session of the week. We’re excited to see a shift toward more comprehensive education in addiction medicine and grateful to the University faculty for supporting this change. A full and nuanced education about addiction must acknowledge the complexities of the origin of addictive behavior, the intersection of race, class, state violence, and mental health on patterns of drug use, the challenges in recovery, and the disastrous effects of the War on Drugs and the criminalization of substance use disorders in our communities. While we acknowledge the strides being made, we must also recognize that these elements require more attention as we recognize that patients with substance use disorders will be present in our future practices regardless of our specialty. Until then, we must push for a future where addiction medicine is not just a niche or sub-specialty but rather a perspective that can be brought to all areas of medicine. MetroDoctors
The Journal of the Twin Cities Medical Society
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