Kentucky Doc Fall 2018

fall 2018 • volume 10 • issue 3

Opioid Crisis How did the U.S. (and Kentucky) end up with this drug abuse epidemic?

COMPASSION Treating Addiction Traci Westerfield MD

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CONTENTS

Your Local Health Department: Doing Its Part to Combat the Opioid Crisis PAGE 5 Steven Stack, M.D. and the Opioid Crisis in the Emergency Department PAGE 7 Physician Health & Wellbeing: R.A.I.N. A Mindfulness Based Stress Reduction Practice PAGE 10 Profile in Compassion: Both Mine and My Patients PAGE 12 The Opioid Epidemic Origins of the Current U.S. Opioid Epidemic PAGE 16 Community News PAGE 26 Prosthetics: Hi-Tech Artificial Limbs PAGE 29 The Effects Of Chronic Pain On Mental Health PAGE 31

EDITORIAL

BOARD MEMBERS Robert P. Granacher Jr., MD, MBA editor of Kentucky Doc Magazine Tuyen Tran, MD Lowell Quenemoen, MD Tom Goodenow, MD John Patterson, MD Thomas Waid, MD Danesh Mazloomdoost, MD

FROMTHEEDITOR • FALL 2018 Robert P. Granacher Jr., MD, MBA, Editor-in-Chief, Kentucky Doc Magazine

As I sit here this morning preparing this letter, President Trump has just finished speaking at the General Assembly of the United Nations in New York City. He is focusing the world on the opioid crisis, and 130 countries have signed on with the U.N. to provide help with this issue. In Lexington, Kentucky, we know the problem well and have been grappling with it for at least a decade. The purpose of this topical edition of KentuckyDoc Magazine for Fall 2018 is to broaden the scope of informing our physicians about opioid crisis issues. To do this, members of the Editorial Board of KentuckyDoc Magazine have interviewed our colleagues on the front lines of the crisis.

LMS President, Tuyan Tran, M.D. provides a succinct overview of the opioid epidemic. He begins with the cultivation of the opium poppy by the Sumerians of Mesopotamia around 3400 B.C. and brings us to the current day 5500 years later. It is well worth your time to read.

Dr. Granacher, Past President of the LMS, interviewed Steven Stack, M.D., Past President of the American Medical Association and a current active Emergency Department physician.

Steve provides both the perspective of a Lexington Emergency Department physician dealing with opioid issues daily, and also the policy perspective of a past-AMA President.

His insight provides an overview of clinical, demographic and social issues at the Emergency Department interface in a community hospital in Lexington, Kentucky.

Tom Goodenow, M.D., LMS member, provides an interesting insight into the direct care and policy issues at the Lexington Health Department. He shares important information from Craig Humbaugh, M.D., Commissioner of Health for Fayette County. In particular, this article provides a window into the current needle exchange program, distribution of Narcan kits, and the complementary role of the Lexington Health Department to other medical services provided in the community directed toward the opioid crisis.

John Patterson writes in his profile In Compassion section about Traci Westerfield, M.D. Traci is the Director of the HighRisk Clinic at the Pain Treatment Center in Lexington. She shares a personal story of her addiction recovery and also her current role as a physician practicing pain medicine with patients at risk for addiction.

For those of you wishing to deal with your own personal stress reduction, do not overlook Dr. Patterson’s Physician Health and Wellbeing column. He provides an article on a mindfulness-based stress reduction practice (R.A.I.N.S.). It is a very practical method for applying personal stress reduction mindfulness techniques throughout the day while in a busy medical practice.

Please make time to read the Fall Edition of KentuckyDoc Magazine. It is too easy to feel overwhelmed dealing with issues of the opioid crisis in our own practices, and it is worthwhile learning how our colleagues are dealing with these issues within their own personal medical practice life.

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Fall 2018 • Kentucky

Your Local Health Department:

Doing Its Part to Combat the Opioid Crisis

By Thomas Goodenow, MD Not a day passes without some story in the media about the devastating opioid epidemic in this country. Often the item concerns the latest government statistics that show an ominous worsening of some indicator of the crisis – such as a CDC report that estimates that there were more than 42,000 drug overdose deaths in the U.S. in 2016 alone, a figure that was projected to reach 72,000 deaths in 2017, representing a deadly drug overdose about every six minutes.

Invariably Kentucky ranks among the worst states in these statistical analyses, even though the commonwealth has often been a leader in its approaches to the opioid problem, such as the pioneering use of online prescription drug monitoring with the Kentucky All-Schedule Prescription Electronic Reporting (KASPER) system and our state’s requirement of continuing medical education regarding controlled substances in order to maintain a license to practice medicine. In 2011 Kentucky pharmacies dispensed 371 million opioid units. The following year, with passage of House Bill 1 by the General Assembly, the state’s physicians, nurse-practitioners, and dentists for the first time were required to use the KASPER system before prescribing an opioid. In 2017 that number of prescribed opioid units was down to 278 million – a decrease of 25%.

So how did the U.S. (and Kentucky) end up in this opioid crisis? America likely will always have some problem with drug abuse disorders. The current epidemic is notable principally for the rapidity of its rise, the large number and broadly inclusive demographics of its victims, its particular infectious disease accompaniments, and the pronounced lethality of its newest abused drugs of choice. It began three decades ago and has manifested itself in three continuing, overlapping, and increasingly lethal waves of drug overdose deaths. The first wave began around 1999 and was associated with a marked rise in authorized

prescriptions for natural and semi-synthetic opioid pain relievers such as hydrocodone and oxycodone, used medically and nonmedically. A second wave followed around 2010 and was associated with a slight slowing in the availability of prescription opioids accompanied by easier availability of cheaper and more potent heroin. The most recent wave had its onset about 2013 and is associated with surging use of inexpensive, readily available, synthetic opioids, such as fentanyl and carfentanyl, that are many times more potent than heroin. The recently released “2017 Overdose Fatality Report” from the Kentucky Office of Drug Control Policy reflects the latest trends in drug use in Kentucky and each of its individual counties, including increasing fatal roles for fentanyl and for mixtures of other controlled substances such as prescription opioids, benzodiazepines, and (somewhat resurgent) illicit methamphetamine.

Management of this epidemic will require a concerted, multidisciplinary effort involving the public, the government, and the expertise of the scientific and medical communities. What is the role of the health department, specifically our local LexingtonFayette County Health Department (LFCHD)?

Kraig E. Humbaugh, MD, MPH heads the LFCHD. As Commissioner of Health and the department’s only physician, he oversees six divisions and 160 full time employees, including a nurse-practitioner, nurses, environmental health educators, and others working out of two Lexington locations – a main building at 650 Newtown Pike and a second facility, largely devoted to Women, Infants, & Children (WIC) education, at 2433 Regency Road. Dr. Humbaugh reports to the Board of Health, which in turn determines long term planning and future goals for the LFCHD while also insuring that its policies and goals are carried out. An organizational chart, a list of current Board of Health members, minutes of past Board meetings, and notices of future meetings are posted at the LFCHD website lexingtonhealthdepartment.org.

The simply stated mission of the LFCHD is “helping Lexington be well.” It does this through the data it collects and shares – data that might find its way into reports like those cited earlier – and by policies it promotes and services it provides. These services are extensive and include a narrowly focused health clinic, education programs, environmental inspection and protection, and infectious disease monitoring and control.

Dr. Humbaugh stresses that the aim of the health department is to complement, not compete with, other medical services in the community. “We are not and do not pretend to be a primary care agency,” he says. “Our real niche is prevention.”

Regarding the opioid epidemic, this chiefly involves harm reduction strategies directed to the subset of opioid-addicted individuals who are injection drug users of heroin or even more potent synthetic opioids. The two main approaches – needle exchange programs (NEPs) and naloxone (Narcan) distribution and training-- are aimed not only at reducing overdose deaths but also at reducing serious infections and other undesirable consequences for the individual and for the community while also serving as a potential first step on the road to recovery and wellness.

In 2015, Senate Bill 182 (“the heroin bill”) was passed by the Kentucky General Assembly in response to a rapid rise in heroin overdose deaths in the state. The law allowed health departments to distribute new needles to injection drug users in exchange for used needles. Heroin deaths had especially skyrocketed in Fayette County, so the LFCHD had already prepared extensively with government officials, law enforcement personnel, infectious disease specialists, mental health experts, etc. Operation of the NEP in Lexington was approved by the Urban County Council and the Board of Health by mid-July. and the program began operation less than two months later as only the second such program in the commonwealth (the other being Jefferson County). Its goals were to

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reduce the spread of bloodborne viruses like HIV and hepatitis C and to reduce the risk of community exposure to these diseases by disposing of used needles safely. (Previously NEPs elsewhere had been shown to prevent the spread of infection by HIV and perhaps hepatitis C.) Other important goals were to serve as a center for services for injection drug users, to reduce death from opioid overdoses, and to build client trust to foster referrals to substance abuse counseling and treatment services. The program is free of charge, anonymous, and supported by law enforcement officials.

Initially the NEP was open for only a few hours one day a week and served 7-8 clients per hour. Now it is open 3 p.m. to 6 p.m. on Wednesdays and 11 a.m. to 4 p.m. on Fridays at the department’s Newtown Pike location, serving over 20 clients per hour (200-220 per week). From its inception on September 4, 2015 through July 25, 2018, the health department’s NEP distributed over 600,000 needles to 3,239 clients on 15,590 visits.

Most clients have been male (59%) from Fayette County (75%), with all adult ages represented (most often ages 26-34 [39%] or 35-43 [30%]). Over 90% of the needles have been distributed on return visits, at which the ratio of needles returned to needles distributed has been 0.90:1. Returning individuals comprise most of the clientele, but about 15% of visitors to the NEP on any given day are new to the program.

In addition to the actual needle exchange, NEP clients are offered education and optional hepatitis C and HIV testing by the LFCHD’s Disease Investigation Specialists and the staff at AIDS Volunteers of Lexington. Referrals for confirmatory testing are made as necessary. (Kentucky ranks fourth nationally in incidence of new hepatitis C cases, with injection drug use as the predominant risk factor. About 50% of local NEP clients test positive for hepatitis C, which is highly treatable with newer medications. The number of new HIV cases in Kentucky has been stable recently at about 350-360 per year, although there are occasionally clusters of patients seemingly related to injection drug use. About 15% of new HIV patients in Fayette County have injection as their main risk factor for the infection.)

Management of this epidemic will require a concerted, multidisciplinary effort involving the public, the government, and the expertise of the scientific and medical communities.

In a paper published earlier this year, it was estimated that the total economic toll of the opioid crisis in the U.S. since 2001 has exceeded $1 trillion dollars, including a whopping $93.8 billion alone in 2016 – a figure projected to reach approximately $200 billion for the year 2020. So, it is important to ask whether needle exchanges and their ancillary services are cost effective. The answer appears to be a resounding “yes.”

Consider that the LFCHD’s needle exchange program budget is around $100,000$150,000 for fiscal year 2018. Compare that to the CDC’s estimates of the average cost of treating just one case of hepatitis C ($32,000-$56,000) or the cost of a lifetime of HIV treatment for a single patient ($379,000).

Another important ancillary service of the LFCHD is harm reduction via the distribution of naloxone (Narcan) kits, each containing two doses of the often lifesaving opioid antidote in the form of a nasal spray. The second of the two doses can be utilized 3-5 minutes after the first if the initial response seems insufficient. The drug is essentially harmless if someone’s difficulties turn out to be due to something other than an opioid overdose. Training in the use of the naloxone kit is easy, requiring about 15-20 minutes at most. Nearly 1,600 of these kits, which can cost up to $140 each if purchased privately, have been obtained at great savings and distributed by the LFCHD through partnerships with organizations like the UK College of Pharmacy and the Kentucky Injury Prevention and Research Center (part of the UK College of Public Health). Hours for naloxone education and distribution are Fridays 11 a.m. to 1 p.m. at the LFCHD’s Newtown Pike location.

Quantities may be limited.

Another vital health department ancillary service is on-site referral to substance abuse counseling and treatment. The client is not required to sign up for this to continue in the NEP but is offered the opportunity to voluntarily pursue this course of action.

Thus, the health department’s harm reduction programs can also serve as an entry point to psychosocial support services and pharmacological treatment – a chance for individuals to turn their lives around when they feel ready to take that next big

step. The LFCHD itself does not have the means to provide this tertiary preventive service, buy it can arrange treatment through experienced partners such as the city’s Social Services’ Substance Abuse and Violence Intervention program, Chrysalis House, and bluegrass.org. Since April 2016 the LFCHD has made over 135 treatment referrals.

Absent an unexpected, huge influx of money, even the most optimistic public health experts foresee little likelihood that the opioid epidemic can be significantly controlled before the mid or late 2020s. The number of people receiving proper treatment is minuscule compared to the number of individuals newly presenting with opioid use disorders. Meanwhile and in the future the health department will continue to play a vital role in preventing complications and facilitating the treatment of individuals caught up in this public health crisis.

References: • Kolodny, A, et al. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction.

Annual Review of Public Health 36: 559574, (March) 2015. (This provides a nice overview of the hstory of the opioid crisis, at least through its first two waves.)

• Kentucky Office of Drug Control Policy 2017 Overdose Fatality Report (viewed on internet by entering “Kentucky Office of Drug Control Policy issues 2017 Overdose Fatality Report”) • (Lexington-Fayette County Heath Department Needle Exchange Program can be reached at {859} 288-2437 or via email at lfchd@ky.gov or lexingtonhealthdepartment.org.)

About the author: Tom Goodenow, MD practiced medicine for 42 years, the last 37 as an endocrinologist at at the Lexington Clinic.

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Fall 2018 • Kentucky

Steven Stack, M.D. and the Opioid Crisis in the Emergency Department

By Robert P. Granacher, JR., MD, MBA I had the opportunity to interview Steven Stack, M.D. regarding opioid issues confronting emergency department physicians. Steve is well known to many of us, as he is a very recent president of the American Medical Association and currently is employed as an ED physician at St. Joseph Hospital East.

Steve’s opinion of the opioid crisis currently is that it is sad, tragic, and an enormous problem. From the patient perspective, the patients that Steve sees are very hopeless and have limited

resources. The nature of their disease leads to poor compliance with treatment recommendations and a continuation of their substance use disorder (SUD) or relapse.

From the clinician perspective in the ED, opioid use disorder (OUD) is a destructive condition to patients. For instance, Steve noted that after receiving Narcan for over dosage and then being seen in the ED, patients are often confused, belligerent, and must be kept in observation for quite some time before a reasonable history can be obtained. Dr. Stack does note that by talking with OUD patients and being respectful, you can get more information than you would expect. It is not unusual for

OUD patients to answer questions about how they started on the substance, their use of it, frequency of use, etcetera. The greater percentage of these individuals respond well to this approach. Most OUD patients are used to being rejected when presenting for health care, and thus tend to respond negatively to rejection. Dr. Stack has learned that with a positive approach from the physician, they are much more willing to provide needed information.

Steve does report that the stress to an ED physician is so great that after one completes their shift, it is not unusual to feel as if you OPIOID CRISIS Continued on Page 9

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The stress of dealing with SUD and OUD patients in the emergency department is tremendous upon the staff.

OPIOID CRISIS continued from Page 7

have PTSD. The issue of substance use disorder (SUD) was graphically told to me

by Steve. He very recently saw an alcoholic man who was placed on a stretcher in a hallway because of continuing intoxication.

For the next 45 minutes, he used personal derogatory ad hominem language toward all staff near him. Such SUD patients tie up beds in the emergency department for 8 to 14 hours. Medical staff cannot communicate with them until they become lucid. It is also very difficult for ED physicians to obtain consultation with a behavioral health person by the time the SUD patient becomes capable of discussion.

Steve’s wide experience as president of the American Medical Associations, and the travels and consultations he engaged in while president, have enabled him to see the opioid problem from perspectives other than his own current treatment of patients.

For instance, working in an emergency department is a very high stakes issue for physicians. The SUD and OUD patients are very angry people generally. There is usually no support system for them, and the ED physician has no place to easily refer patients. The link of the ED physician to hospitals that treat substance abuse is meager at best. For instance, in the St. Joseph Hospital system, the nearest major psychiatric and substance use hospital is in Louisville at Our Lady of Peace. While they are generally very helpful to ED physicians, it is a 90-minute ambulance ride to Our Lady of Peace. For OUD and SUD patients, this poses some risk by traveling that far for

that long on an interstate highway. While Our Lady of Peace staff is very cooperative in their attempts to help, they still cannot cover the needs of the ED physician fully.

Comorbid physical medical problems of SUD patients are also a substantial issue for the ED physician. For instance, intravenous drug users commonly develop upper extremity abscesses. It is difficult to get other physicians to see them for the surgical needs they have. They are very difficult patients to engage, and they have high rates of signing out of the ED against medical advice.

Dr. Stack reasons that to manage the OUD patient in emergency departments, it is necessary to have a well-functioning, competent, aggregate team in the ED. That is difficult to accomplish in most hospitals. Moreover, he agrees that there is a significant current need for flow maps for critical treatment teams to follow with SUD patients and provide appropriate care.

The stress of dealing with SUD and OUD patients in the emergency department is tremendous upon the staff. These patients tend to “suck the air out of the room.” Steve believes that in an emergency department seeing 100 patients a day, at least one to two of those in Lexington will be SUD patients. Every day, the entire panoply of SUD patients runs about 7 percent to 10 percent of the patients seen. This requires approximately 15 percent to 20 percent of clinical time used in the emergency department.

Overdose OUD patients are a major issue for most emergency departments.

They must be watched carefully, which

takes significant staff resources. If they have received Narcan, they often are belligerent, confused, and fighting for a while. There are no resources in most community-based hospitals to provide non-medical staff to convince these patients to be referred for appropriate SUD treatments. Moreover, the homeless population is a serious stress to ED physicians. Again, Steve provided me a direct clinical example of a recent patient who left against medical advice from the University of Kentucky. He had been seen at Central Baptist Hospital before coming to St. Joseph Hospital East and refused the other hospitals. At all facilities the patient had used, he refused any offers for help with substance use.

Lastly, Dr. Stack stressed that physicians want to be patient advocates for these individuals, but you must be a pragmatist as well. He notes that a physician will burnout trying to solve serious social-medical problems of the SUD patient unless he/she has non-medical resources to help deal with the complex social issues of these persons and provide treatment for substance use.

Overall, it is the author’s opinion that the opioid crisis will defy significant management unless resources can be developed to provide ED physicians and treaters of SUD significant consultation support, and a developed referral system that is willing to take these difficult patients in transfer for inpatient/outpatient treatment.

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PHYSICIAN HEALTH AND WELLBEING

R.A.I.N.

A Mindfulness Based Stress Reduction Practice

By John A. Patterson MD, MSPH, FAAFP Former Surgeon General Vivek Murthy MD has sounded the alarm regarding our country’s epidemic of stress.1 He calls for a serious national effort to mitigate the corrosive effect of chronic stress on every organ system. He calls for a nationwide campaign to spread a preventive, behavioral lifestyle prescription of healthy eating, physical activity and genuine social support (other than social media). Based on solid peer-reviewed evidence, he also recommends meditation as a health promoter and stress buster. As Surgeon General, he offered meditation training to his entire staff. They often meditated together at work.

Mindfulness is the leading meditation and awareness practice worldwide, with broad applications across the lifespan and across cultures in health, medicine, education, business, law and criminal justice.

A 2014 meta-analysis in JAMA2 concluded that anxiety, depression and chronic pain can often be improved by the addition of mindfulness-based stress reduction (MBSR) to a patient’s treatment plan.

The R.A.I.N. practice is one of many useful tools taught in MBSR. It was developed by psychologist and mindfulness teacher Tara Brach3 and serves several useful mindfulness goals. It reminds us to direct our attention to the present momentto what is actually happening here and now- rather than spending so much time replaying the past and anticipating the future. It reminds us to fully experience life as it is right now- both the pleasant and the unpleasant- the comfortable and the uncomfortable. It can be a portable tool of self-care and help silence the inner critic of self-sabotage. We can learn to transform self-criticism, self-neglect and self-judgment into self-kindness, self-friendliness and selfcompassion.

Practicing R.A.I.N. Begin by pausing anytime you remember to do so. The frequency of remembering increases the more often you do the practice, especially if you keep a personal practice journal each day or practice with a

dedicated group. This journaling helps you hold yourself accountable to your goal of mindful self-care.

R: Recognize what is happening Anywhere, anytime, simply ask yourself: “What is my immediate experience?

What is happening inside me right now?”

Turn your attention inward with genuine, natural curiosity, letting go of assumptions, automatic responses and preconceived ideas.

Listen with kindness to your body, heart, thoughts, emotions, feelings, or sensations just as they are- right here- right now.

A: Allow life to be just as it is Allowing means “letting be” and “being with” whatever thoughts, emotions, feelings, or sensations you are experiencing. Simply allow your experience, whether you like it or dislike it, remaining open to being present with “what is.” Allowing increases your capacity for “letting things be” and develops the positive personality trait of equanimity.

I: Investigate inner experience with kindness Investigation means being truly curious, paying close attention and asking yourself, “What is happening inside me?” Experiment and engage in an active inquiry into your experience. Ask yourself questions like: “What most wants attention? How am I experiencing this in my body, my mind, my emotions? What am I believing? What does this feeling want from me?”

Really roll out the welcome mat to all your experience with curiosity, openness and acceptance. Brach reminds us to “Investigate with kindness. Without this heart energy, investigation cannot penetrate; there is not enough safety and openness for real contact.”

N: Natural Awareness (or Non-identification) The first three steps of RAIN require your active intention on focused attention.

In contrast, the N of RAIN expresses the result of these first 3 steps: an experiential, non-verbal realization of your natural awareness. There’s no action required.

All of our physical, mental and emotional experiences have arisen within our natural, pure, open awareness. Now we allow

awareness itself to arise spontaneously.

Importantly, we no longer ego-identify with our experience. We simply rest in natural awareness.

You can use the R.A.I.N. written document4 and audio recording5 below as guides for your own practice or as resources for your staff and your patients.

Curing our national epidemic of stress can begin with skillfully managing our own.

Resources 1. A nation under pressure- The public health consequences of stress in America September 7, 2017 NIH webinar with Vivek Murthy, MD https://nccih.nih.gov/news/events/ lectures/SES17 2. Goyal M, Singh S, Sibinga EMS, et al.

Meditation Programs for Psychological Stress and Well-beingA Systematic Review and Meta-analysis. JAMA Intern Med. 2014;174(3):357–368. doi:10.1001/jamainternmed.2013.13018 3. Tara Brach, PhD, psychologist, founder of Washington Mindfulness Community https://www.tarabrach.com/ 4. R.A.I.N. handout pdf https://www.tarabrach.com/ wp-content/uploads/pdf/RAIN-of-SelfCompassion2.pdf 5. R.A.I.N. practice audio recording (11 minutes) https://palousemindfulness.com/ meditations/RAIN.html About the Author Dr. Patterson Chairs the Lexington Medical Society’s Physician Wellness Commission, is past president of the Kentucky Academy of Family Physicians, is board certified in family medicine and integrative holistic medicine and is a certified Physician Coach. He teaches Mindfulness-Based Stress Reduction for the UK Health and Wellness Program and Saybrook College of Integrative Medicine and Health Sciences (Oakland). He owns Mind Body Studio in Lexington, where he offers integrative mind-body medicine consultations, specializing in stress-related chronic conditions and burnout prevention for health professionals.

He can be reached through his website at www. mindbodystudio.org

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PROFILE IN COMPASSION

Both Mine and My Patients Traci Westerfield MD treats and teaches patients struggling with addiction and chronic pain. One of her most effective therapeutic and educational tools is her powerful and compelling personal story.

For that reason, I will share her story here in her own words- for the benefit of our physician colleagues, our patients and our community.

By John A. Patterson MD, MSPH, FAAFP In August of 2011, the American Society of Addiction Medicine released the following revised definition of addiction: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and

other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (https://www. asam.org/docs/default-source/public-policystatements/1definition_of_addiction_long_411.pdf?sfvrsn=2 )

doc

Fall 2018 • Kentucky Teenage addiction “My first recollection of having a problem with alcohol use was at the age of 14, when I took a bottle of bourbon whisky to school and drank to the point of toxicityrequiring an overnight stay in the hospital.

Throughout high school and college, my drinking and substance abuse led to DUI arrests, court appearances and late-night phone calls to my parents for help.”

and ask for help. The help came from what was then the Kentucky Board of Medical Licensure’s Impaired Physicians Program. I was relieved of my duties as a resident and given the opportunity to go into a residential drug treatment center in Atlanta.”

Proud to Partner with You Med school and residency addiction “Along the way, my desire for approval and achievement led to success in academic studies and I was accepted into UK College of Medicine (much to my surprise) in 1992. I recall thinking “it’s going to be different now. I’m a medical student, time to straighten up and get it together...” Within the first month of medical school, my classmates had elected me to be our social chair and I proceeded to place myself in the center of drinking and planning parties.

Following medical school, I focused in the practice of anesthesia, following in my Dad’s career path and thought again, “its going to be different now, I’m a doctor, time to straighten up.””

“It wasn’t different. My alcohol and substance use continued. Things took a serious turn for the worse when I began abusing opioids during anesthesia residency.

Through what I now see as a set of miracles, I was able to find the courage to surrender

Rehab- Relapse- Rehab “I connected with recovery, but it was only superficial. I had not yet fully surrendered to the disease. I thought if I could just stop abusing opioids, perhaps I would be able to still drink alcohol. I could not imagine my life without alcohol.

I returned to the anesthesia residency only to suffer a relapse which could easily have resulted in my death. But that was not to be my story. The relapse resulted in termination from the anesthesia residency two months into my fourth and final year. I returned to the same residential treatment center in Atlanta, staying for six months and this time it was different. My parents had to pull away and let me experience this without their support. This was an incredibly painful experience, as my Mom was going through treatment for small cell lung cancer at that time. I knew I was going to lose her and didn’t know if I could get through that without using drugs and alcohol, which at the time was my chief coping skill.”

“During this second stay in residential treatment, my whole attitude and outlook on life changed. I had fully surrendered,

Five Star Senior Living Referral Guide

13

admitted defeat, accepted help from something greater than me and experienced a spiritual awakening as a direct result of working the 12 steps of recovery.”

12 Steps “My sobriety date is November 26, 1999. I continue involvement with a 12-step program and have maintained abstinence from all mood-altering substances and alcohol since that date. For the first 7 years, I participated in a monitoring program with The Kentucky Physicians Health Foundation.

I am forever grateful for the support from Dr Burns Brady, Dr Jim Jennings and now, Dr Greg Jones. I was allowed to return to work as a physician at UK Hospital in 2001 and completed a family medicine residency in 2003. I passed my family medicine boards in December of 2003, and in this same month, lost my Mom.” “With the support of the 12-step fellowship and my friends and family, I was able to get through this without drinking or using drugs. During the family medicine residency, I had discovered a passion for treating and helping patients that were suffering from the disease of addiction. I moved to Gainesville, FL and completed a fellowship in addiction medicine, becoming ASAM certified in addiction medicine COMPASSION Continued on Page 15

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COMPASSION continued from Page 13

in 2004. I have also studied urine drug testing/toxicology and became certified as a Medical Review Officer. I’ve been practicing mindfulness meditation and yoga for many years. In 2013, I became a certified yoga instructor and will soon achieve advanced yoga teacher certification.”

“I continue participation in 12 step recovery programs. I have a sponsor and I have sponsored many women over the past 18 years, including other physicians. I have served as peer support for the Kentucky Physicians Health Foundation for more than 6 years.”

Practicing compassion for myself and my patients “My compassion for patients struggling with drug dependency comes from this direct personal experience with addiction.

I really am concerned about the abuse and over-prescribing of Suboxone. Just like the overprescribing of antibiotics for non-bacterial conditions, Suboxone is being overutilized and is not addressing the underlying problem. I do see its benefit in short term use to stabilize and engage someone into the treatment process, but without some kind of spiritual awakening, addiction is just too complex a disease to be treated with a drug. If we neglect the spiritual suffering of these patients, we will do more harm than good.

I’ve declined to be a prescriber of Suboxone.”

“I treat addiction using a 12-step model.

I teach yoga and mindfulness classes twice a week and share my personal story, using my experience to educate about the disease of addiction and give hope that there is a way out. I take the patients hiking. We learn together how to live one day at a time and how to reconnect with a spiritual life.”

“I see patients with high risk situations such as termination from a previous pain clinic, repeated inappropriate urine testing, high dose opioid use and alcohol use with opioid medication. Sometimes it

is appropriate to offer a trial of continued opioids- sometimes it is not. I treat each patient individually, taking into consideration the pain condition and, depending on the situation, I consider if opioids are appropriate and safe. When it is clear that there is a co-occurring substance use disorder, I discuss my findings with the patient, helping with locating treatment and offering information on 12 step meetings and treatment options in the community. If the patient is at that time on high dose opioids, I advise them I plan to taper and stop opioids, but that this will be done gradually, and in a manner that will minimize acute withdrawal. If the dose is reduced gradually and the patient will take the medication as prescribed, severe withdrawal symptoms can be avoided.”

“My practice allows me to have an hour with a new patient and I spend much of this time building rapport, offering education and instilling hope for effective alternatives to opioids. I focus on non-pharmacologic methods of chronic pain management, encouraging mild, daily exercise and gentle movement, learning and adopting new coping skills and self-care. Some are not able to follow the treatment plan due to the severity of their addictive disorder and continue to have inappropriate urine testing and manipulative behaviors. Unfortunately, they often discharge themselves from the practice and are lost to follow up- enrolling in another pain clinic or seeking substances illicitly.”

“I see the misunderstanding of addiction among my colleagues- their lack of appreciation of addiction as a primary disease- not a symptom of an untreated psychiatric condition or poor parenting. Patients have also inherited this misunderstanding. Over these past 18 years in recovery from my addiction, I have come to accept and not judge myself.

This carries over to my care of patients, who sense that I am there to help and not to judge. My conscious creation of a therapeutic office includes an aquarium,

potted plants, windows and natural light, and a therapy dog named Q-tip. I dress casually to avoid intimidating patients. I often have to advise patients that I do not recommend use of opioids for their chronic pain condition. This provokes a dramatic and emotional response in some individuals.

I try to diffuse this situation by providing a supportive, caring and compassionate space. I always strive to offer dignity and respect, even if there is dishonesty about drug use or deception discovered during the encounter. My response is non-blaming and non-shaming. I want to offer help and hope rather than judgment.”

My message for physicians in training and in practice “The opioid crisis in Kentucky and across America is not just a medical crisis. It is a spiritual crisis. I believe the solution is much more complex than a pharmacologic product. These are only temporary band aids to a gaping, hemorrhaging spiritual wound. The solution must include the spiritual. As physicians, we may not all be equipped with the skills to provide this spiritual help ourselves, but we can refer to community resources that are.”

“We all must find the inner resource that fills our spiritual cup- whether it is a religious practice, community connection, meditation, yoga- some way to connect to something bigger than ourselves.

Carrying the message of hope and recovery to others, to the readers of this article and in the patient encounter - this keeps me connected to my spiritual center and allows me to stay sober.”

On behalf or our physician readers, I wish to extend a heartfelt thanks to Traci Westerfield for sharing her personal story.

About the Author Dr. Patterson chairs the Lexington Medical Society’s Physician Wellness Commission. He is a certified Physician Coach and specializes in stress-related chronic conditions and burnout prevention for health professionals.

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Patients appreciated the relief and doctors felt empowered.

Fast forward to present day. Despite our tremendous advancements in medicine, there are many diseases including chronic pain that continue to elude our understanding.

Physicians overprescribe opioids.

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The Opioid Epidemic Origins of the Current U.S. Opioid Epidemic

By Tuyen T. Tran, MD, MBA America’s first epidemic of opioid addiction occurred in the 1840s. Mothers dosed themselves and their children with opium tinctures and opioid containing medicines. Soldiers in the U.S. Civil War treated their injuries and diarrhea with morphine (“the Army disease”).1 Drinkers treated their hangovers with opioids. However, the main source of the epidemic was iatrogenic morphine, which coincided with the invention of the hypodermic needles in the 1870s.

It has been estimated that consumption of opioids soared 538% from 1840 to 1890. The Institute of Medicine estimated that by 1900, about 300,000 Americans were addicted to opiates.2 There were few alternatives to symptomatic treatment during the nineteenth century. The pathology of diseases, particularly chronic pain, was poorly understood. An injection of morphine magically alleviated most symptoms, particularly pain. Patients appreciated the relief and doctors felt empowered. Fast forward to present day. Despite our tremendous advancements in medicine, there are many diseases including chronic pain that continue to elude our understanding. Physicians overprescribe opioids. Physicians also overprescribe diagnostic evaluations, labs, imaging and antibiotics.

But, these are all well-intentioned. Physicians do not want to miss a diagnosis which could harm their patients. And they definitely do not want their patients to experience pain. But instead of the 10-20 tablets (3-4 days of analgesics), physicians will often prescribe more than the necessary amount. And it is the leftover pills that cause problems. These pills sit forgotten in the medicine cabinets until a family member, neighbor, or visitor inappropriately abuses them. But the physicians’ contribution to the opioid epidemic also has a sinister side. There are, unfortunately, colleagues who have participated in “pill mill” operations, accepting cash payments in exchange for opioid prescriptions regardless of ailment. (Between 1992-2001, Dr. David Proctor, the “Godfather of Pill Mills,” operated America’s first “pill mill” in South Shore, KY until his arrest.) These doctors damage the reputation of every other physician who is working very hard to help patients.

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In 1980, NEJM published a one paragraph letter from Jane Porter and Hershel Jick, MD, reporting that during their retrospective review of 11,882 hospitalized patients who received narcotics, only four (4) patients were found to have “well documented addiction.”3 In 1986, doctors Kathleen Foley and Russel Portenoy published in Pain that iatrogenic addiction risk was low in 38 chronic non-cancer pain patients treated with opioids.4 In 1995, James Campbell, MD, president of the American Pain Society, promoted, “Pain is the Fifth Vital Sign.” He encouraged physicians to assess pain with as much “zeal as other vital signs” if we were going to adequately treat pain.5 Many of the pain specialists at the time felt that physicians were undertreating pain because of a misconception among physicians regarding opioid use and addiction. They reported that there were no long-term studies implicating chronic opioid use and addiction. (The fact was that there were no long-term studies regarding chronic opioid use whatsoever!) Despite the poor quality of the available studies, the 1986 Foley and Portenoy study was cited repeatedly to support aggressive opioid pain management.

Most concerning, the one paragraph letter to the NEJM was cited 608 times as a “study” supporting opioid safety.3 In 1997, the American Academy of Pain Medicine (AAPM) and American Pain Society (APS) published a consensus statement that there was lacking evidence implicating opioids to addiction.6 In 1998, the Veteran’s Health Administration incorporated pain as the “fifth vital sign” into their national strategy for the assessment and treatment of pain.7 Similarly, JCAHO ( Joint Commission on Accreditation of Healthcare Organizations) embraced the “Pain is the Fifth Vital Sign” and issued standards requiring the use of a pain scale and treatment of pain, especially with opioids.

JCAHO also referred to pain management as a patient’s rights issue, inferring sanctions if the pain was not adequately controlled.8-10 Also, in 1998, the Federation of State Medical Boards (FSMB) issued guidelines stating that “physicians should not fear disciplinary action” from FSMB if prescribing opioid analgesics for “legitimate medical purpose and in the usual course of professional practice.”11 The FDA (Food and Drug Administration) granted its approval of Oxycontin in December of 1995 without evidence of efficacy or safety from any clinical trials! Purdue Pharmaceuticals, the manufacturer of Oxycontin, claimed that the long-acting formulation was “believed to reduce” its appeal to drug abusers compared to shorter-acting analgesics. The FDA believed them! Pharmaceutical companies, particularly Purdue, aggressively marketed their analgesic products, citing “evidence” that opioid use was efficacious and safe,

and contributed substantially to regulatory organizations and professional organizations.

Another factor contributing to this perfect storm was Press Ganey, a survey of patients which began in 1985 to identify opportunities to improve patients’ experiences. Collection of data was necessary for improvement; but, the distinction between patient satisfaction and quality of care became blurred. Press Ganey monetized their concept and promoted the notion that patient satisfaction was a proxy for quality of care. (There is still no definitive data to correlate patient satisfaction and quality of care.) The final ingredient was CMS (Centers for Medicare and Medicaid Services). CMS realized that the current pay for volume healthcare system was insolvent; thus, CMS developed the value-based purchasing program.

Scoring for hospitals depended upon performance on equally weighted metrics: 1) Processes of care, 2) Outcomes of care, 3) Efficiency, and 4) Patient experience.

The patient experience was collected via HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys which included patient scoring of satisfaction with pain management. “Did hospital staff do everything they could to help you with your pain?”

With the aforementioned factors in place, it is easier to understand the following contributors to the opioid epidemic because these factors are unintended responses/ reactions. The predominant thought was that there were too many patients suffering unnecessarily because of inadequate pain management. Physicians needed pain management guidelines, to include the use of opioid medications. Physicians needed education to dispel the concern for addiction. Additionally, insurances were not reimbursing for non-pharmacologic modalities for the treatment of chronic pain. The landscape was perfect for the pharmaceutical companies to capitalize on the pain revolution. Since regulatory organizations and professional medical societies were doing such a great job of promoting the pharmaceutical companies’ marketing strategies, financial contributions (or payments) were justified (from a pure business perspective). Everyone was doing their part to expose the undertreatment of pain and promote the opioids are safe and efficacious propaganda.

Since reimbursement to hospitals were tied to patient satisfaction, hospital administrators were forced to implement initiatives to improve patient satisfaction scores and avoid a penalty. CMS only required 300 surveys in a 12-month period.

And if only a small number of patients actually completed and returned patient satisfaction surveys (estimated to be around 25%), a single poor survey could significantly impact whether the hospital

achieved the required 90% percentile goal.

Thus, hospitals coerced physicians (via withholding payment or bonuses) to ensure that every patient was satisfied, especially when completing the survey questions regarding adequate pain management.

When patients requested/demanded opioid pain medications, physicians were often compelled to satisfy the patients, despite their reservations about the need for opioids.12-14 As the prescription opioid problem escalated, the spike in opioid related overdose deaths caught the public’s eyes.

This resulted in a cascade of reflexive responses which unintentionally facilitated the reintroduction of heroin and later fentanyl to Americans. It was easy to see.

If the amount of prescription opioids were reduced, there would be less prescription opioids to abuse and that should result in decreases in opioid related overdoses and deaths. Thus, the campaign to limit prescription opioids began. Legislators demanded implementation of prescription drug monitoring programs (PDMPs) to mitigate doctor shopping. It also allowed physicians to identify patients who were already receiving other opioid or scheduled medications. Various medical societies, CDC, and governmental agencies all switched their stances on the treatment of pain, cautioning physicians regarding the danger of opioid addiction.

Law enforcement aggressively sought and closed the numerous “pill mills” throughout the country. Naloxone kits were widely dispersed to treat overdoses.

The message was clear, physicians must stop overprescribing opioid medications.

But other than the American Society of Addiction Medicine (ASAM) or a handful of physicians who were treating addiction, there were no plans for the void which these interventions created. That is, what was the plan for the patients who were already addicted to opioids? With all of the prescription opioids gone, what were these addicted patients going to use?

Coincidentally, it was around this time that several states were decriminalizing marijuana. More American marijuana customers were growing their own supply.

The wholesale price of marijuana dropped from $100 per kilogram to less than $25.

Farmers in Mexico, particularly the “Golden Triangle,” the region of Mexico’s Sinaloa state which produced the country’s most dangerous gangsters and largest marijuana producers, quickly changed their crop to opium poppies, heroin. With a large, eager American demand from addicts who had their supply of prescription opioids quickly removed, the Mexican heroin suppliers had an immediate market. Not only was there an abundant supply of opioids (heroin from Mexican suppliers), the cost of heroin was relatively cheaper. The prices of

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The FDA (Food and Drug Administration) granted its approval of Oxycontin in December of 1995 without evidence of efficacy or safety from any clinical trials

prescription opioids or heroin depend upon location, availability on the streets, and the heroin’s “purity.” The current market value of Oxycodone is about $1 per milligram and based upon patient testimonies during treatment, a typical addict will use 80-160 mg per dose up to 4-5 times per day (about $400/day). Money was usually the limiting factor. On the other hand, a gram of heroin has a street value of about $100 and a typical dose is 5-20 mg 4-5 times per day ($10/ day). (For in-depth details of how clever Mexican heroin entrepreneurs capitalized on the American demand for opioids, read DreamLand: The True Tale of America’s Opiate Epidemic.)18 Strategies to Combat the Opioid Epidemic To effectively implement strategies to combat the current U.S. opioid epidemic,

there are certain myths regarding addiction which require dispelling. The most significant misconception is that addiction is related to poor individual choices, moral failures, and/or weak willpower. Compulsion to use drugs is a voluntary choice. MAT, also previously known as opioid replacement therapy, is substituting one addiction with another. The best way to combat opioid addiction is without medication. These attributes (stereotypes) contribute to the stigma which often shame people who have addiction, their family members and associates. These fallacies will harm those who are at most risk! Similar to other medical conditions (emphysema, heart disease, hypertension, diabetes), voluntary unhealthy behaviors (or choices) do contribute to the disease. We promote proper dietary changes to the diabetic who consumes excessive sweets. We discourage patients

who smoke. We encourage our patients to exercise. But we do not withhold evidencebased treatment from patients who do not comply with our recommendations! Chronic opioid use causes changes in the brain reward system which depresses the addicted person’s valuation of normal motivational stimuli (food, social interactions, sex) and shifts it toward more potent reward stimuli such as opioids. As discussed, there are also simultaneous changes causing dysphoria and discomfort which drives an addict to use opioids to mitigate the aftereffects of opioid use. We should constantly discourage patients from further use of opioids; but, we should also continue to offer them evidence-based treatment.

Abstinence, the complete cessation of drug use, has been the gold standard for addiction treatment in the U.S. for many years. Originally created for alcoholism,

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Not all of these patients require opioid pain medications; but, what are their options? There are not enough pain specialists to properly diagnose or perform injections/procedures.

the model is currently used to treat all addictions. After the creation of AA (Alcoholics Anonymous) in 1935 and the publication of “The Big Book,” written by William Wilson to describe how to recover from alcoholism, the model (also referred to as the Minnesota Model) was spread to not-for-profit organizations such as the Hazelden Betty Ford Foundation, the premier residential and outpatient facility for addiction, the nation’s largest addiction and recovery publishing house, a fully accredited graduate school of addiction studies, and an addiction research center. Although the model is based primarily on AA principles, it added medical and psychological components. In 2006, a Scottish study followed 695 recovering alcoholics for 33 months following treatment using this model and reported only 5.9% of females and 9% of males had remained abstinent for at least 90 days.19 In regards to efficacy for opioid addiction, there are no reliable or accurate studies to support the use of abstinence. In 2012, the Hazelden Betty Ford Foundation announced that it has incorporated MAT into its treatment plan for opioid addiction.

Multidisciplinary approaches to limit the supply of prescription opioids have been successful. Dr. Patrice Harris, Chair of the AMA Opioid Task Force, announced Apr 19, 2018 that between 2013 and 2017, there was a 22% decrease (55 million less) in opioid prescriptions.20 Physicians and patients are aware of the dangers of opioid addiction. Many professional organizations have created pain management guidelines for physicians. Regulatory and legislative organizations have tightened restrictions for the prescribing and monitoring of opioid pain medications. Naloxone kits are readily available to mitigate overdose deaths. Law enforcement has diligently worked to disrupt the heroin traffic.

And most important, there has been tremendous promotion of treatment for people already addicted to opioids. This intervention was lacking during the initial response to the prescription opioid crisis.

Successful interventions to limit the supply of prescription opioid drugs created an imbalance of supply versus demand and drug dealers exploited the opportunity with heroin to satisfy the unmet demand for opioids. Learning from the 2010 experience,

future strategies to combat the opioid epidemic must include interventions to limit both supply and demand. If treatment for opioid dependence becomes easier to attain than other opioids to relieve withdrawal symptoms, the demand for opioids will decrease. As the demand decreases, the supply will initially rise which will devalue the illicit opioids (heroin, fentanyl), and eventually cause supply to decrease. For example, New York City recently used this approach to tackle the tobacco problem. The city banned smoking in public spaces and significantly raised the taxes on cigarettes. Simultaneously, the city promoted and facilitated the public’s access to free nicotine patches or free nicotine gum. The intervention was successful!

Facilitation of access to opioid treatment is beneficial; but, there are potential pitfalls.

Buprenorphine is an opioid agonist and will induce mu opioid effects to include euphoria, particularly opioid naïve individuals, and respiratory depression. Because buprenorphine is an opioid partial agonist, the ceiling effect will limit the potency of the euphoria and similarly the respiratory depression risk. Fatal overdoses solely due to buprenorphine are rare.21 Most overdoses involving buprenorphine occur when other drugs are taken concomitantly,22.23 usually benzodiazepines and/or alcohol.

(Buprenorphine has the ceiling effect to mitigate respiratory depression; but, benzodiazepines and alcohol do not.)

Despite buprenorphine’s safety profile, ceiling effect, and lower abuse potential,53,54 once buprenorphine becomes “more available,” and/or cheaper, it will become the next abused and diverted drug problem. Yokell et al. conducted an international review of buprenorphine diversion, misuse, and illicit use.24 The authors reported that since France’s adoption of buprenorphine for OUD in 1995, about 20% of buprenorphine patients were misusing the drug intravenously (snorting is also a common delivery mechanism). In Finland where buprenorphine has been used for pain management since 1997 and OUD since 2002, buprenorphine has become the most commonly abused drug. The authors noted that the rise in buprenorphine use in Finland coincided with a decrease in availability of heroin in 2001. Despite reported diversion and misuse, buprenorphine was ranked as the least-abused

or misused opioid in America. Motivating factors for diversion and/or misuse included: price, euphoria, availability, and self-treatment for opioid addiction (non-medically supervised buprenorphine use).

While it is desirable to promote MAT for treatment of opioid addiction, it may be more prudent to encourage treatment which includes MAT, counseling/behavioral therapies, and case management. We want to encourage the use of buprenorphine as treatment, not simply the use of buprenorphine. Promoting many prescribers to simply write for buprenorphine without supporting psychotherapy and case management may create a future state where buprenorphine becomes the next drug crisis. National Institute on Drug Abuse’s principles of effective treatment for drug addiction includes counseling and other behavioral therapies and addressing all of the patient’s needs, not just his or her drug use.56 Patients with opioid addiction have many complex socioeconomic and legal issues. Combine this with poor coping and inadequate social skills (neglected during long-time drug use), these vulnerable patients face significant challenges. For effective treatment of opioid addiction, management of the basic needs of the patients such as employment, housing, food, finances, and social complications (loss of child’s guardianship, criminality) is extremely critical to successful treatment.

Without resolution of these issues, they become constant sources of stress and triggers for drug use. Additionally, patients with opioid addiction require intense counseling and behavioral therapies. With the assistance of MAT, patients’ withdrawal/ dysphoric symptoms are mitigated and they will be much more receptive/capable of participation with psychotherapeutic intervention.

The third crucial element necessary for successful strategies to combat the opioid epidemic is improving the current management of chronic pain. In 2011, the Institute of Medicine (IOM) published “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research,” the most comprehensive report on pain in America.25 IOM reported that 116 million Americans suffer from chronic pain (1 in 3 adults) and estimated

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$560 billion in healthcare and lost productivity costs. “Human suffering is often unnecessary – millions of people get inadequate pain relief for conditions that could be treated or managed.” This is one tough quandary! There is an opioid epidemic and everyone is doing their part to reduce the use of opioids. But what about the patients who have legitimate chronic pain? Not all of these patients require opioid pain medications; but, what are their options? There are not enough pain specialists to properly diagnose or perform injections/procedures. Despite general support for non-pharmacologic modalities such as yoga, physical therapy, massage, acupuncture, and Cognitive Behavioral Therapy (CBT), these services are often not covered by insurances or not available in many rural areas.

Conclusion The opioid epidemic began with a well-intentioned request, “Can we manage patients’ pain better?” As more wellintentioned individuals contributed to the discussion, the question evolved into “Why are patients suffering unnecessarily from undertreatment of pain?” Once regulatory organizations joined, the question converted to mandates, “Pain must be assessed and pain must be treated.” In response to the opioid epidemic, the pendulum has swung completely to the other extreme. “Do not prescribe opioids or you will cause addiction.” Is it acceptable to allow patients to suffer now? Did we go full circle back to the pre-opioid crisis? And the question, “Can we manage patients’ pain better?” still needs answering.

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Kintz P. Deaths involving buprenorphine: a compendium of French cases. Forensic Sci Int 2001;121(1-2):65-9.

Amass L, Ling W, Freese TE, et al.

Bringing buprenorphine-naloxone detoxification to community treatment providers: the NIDA Clinical Trials Network field experience. Am J Addict 2004;13(Suppl 1):S42-66.

Auriacombe M, Fatseas M, Dubernet J, Daulouede JP, Tignol J. French field experience with buprenorphine. Am J Addict 2004;13(Suppl 1):S17-28.

Comer SD, Collins ED. Selfadministration of intravenous buprenorphine and the buprenorphine/ naloxone combination by recently detoxified heroin abusers. J Pharmacol Exp Ther 2002;303(2):695703.

Comer SD, Sullivan M, Whittington RA, Vosberg S, Kowalczyk WJ. Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology 2008;33(5):1179-91.

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ANNOUNCEMENTS AWA R D S N E W S TA F F EVENTS AND MORE

EMAIL brian@rockpointpublishing.com TO SUBMIT YOUR NEWS

Former Leader of Sisters of Charity of Nazareth, Saint Joseph Hospital Administrator Passes Away at Age 96 Sister Michael Leo Mullaney helped expand hospital services for 22 years Lexington, Ky. (September 27, 2018) – Sister Michael Leo Mullaney, a former administrator at Saint Joseph Hospital who helped contribute to the enhancement of health care across the state, has passed away at the age of 96. Sister Michael Leo was born in Quincy, Massachusetts in 1922. In January 1953, she entered the Sisters of Charity of Nazareth and selected her father’s name as her religious name. She graduated from the Bentley College of Accounting and Finance in Boston and later completed a master’s degree in hospital administration from St. Louis University. In 1966, she was appointed administrator at Saint Joseph Hospital.

During her time working at Saint Joseph Hospital, Sister Michael Leo liquidated the hospital’s $1 million debt, introduced computerization into the hospital offices, put

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into practice programs initiated by Medicare and Medicaid, and began plans to expand the hospital and services offered. Under Sister Michael Leo, hospital capacity increased from 285 to 468 beds, making Saint Joseph Hospital the largest hospital at the time in central Kentucky. Sister Michael Leo was responsible for top hospital innovations, including the first physician-staffed emergency room and the first cardiac intensive care unit in central Kentucky, the first balloon angioplasty program in the state, the first hospital helipad in Lexington, and the first computerized tomography (CT) scan equipment in the state.

“Sister Michael Leo worked tirelessly to bring the best technology to Saint Joseph Hospital and the Lexington community,” said Bruce Tassin, market CEO for KentuckyOne Health and president of Saint Joseph Hospital. “Her work within the hospital helped enhance health care for the poor, and patients in our community truly benefitted from her dedication and ministry.”

In 1981, Sister Michael Leo was elected chair of the Kentucky Hospital Association, the first woman to hold this position in almost forty years. In 1987, she received the Kentucky Hospital Association Distinguished Service Award for outstanding service to hospitals in Kentucky. In 1988, Sister Michael Leo was honored by The Bluegrass Chapter of The National Conference of Christian and Jews for outstanding leadership in fostering amity, justice and cooperation among those in central Kentucky.

Sister Michael Leo served as hospital administrator of Saint Joseph Hospital for 22 years before serving as president of The Sisters of Charity of Nazareth Healthcare System from 1988-1992, which included Saint Joseph Hospital in Lexington, Flaget Memorial Hospital in Bardstown, Sts. Mary & Elizabeth Hospital in Louisville, Our Lady of Peace in Louisville, and Saint Joseph London, formerly Marymount Hospital.

She went on to become a lobbyist for the

Kentucky Catholic Conference, a member of the Kentucky Health Policy Board, and Director of Missions for the Diocese of Lexington.

She has received many awards for her work in health care, including receiving the Wade Mountz Visionary Leader Award in November 2004, given to leaders in Kentucky who have made significant contributions to the enhancement of health care in the state. In 2005, she received the Kentucky Women Remembered award. Her portrait is part of a permanent display of outstanding women that can be found in the West Wing of the Kentucky Capitol.

Sister Michael Leo was living at a Nazareth Home in Louisville, where she passed away on Wednesday, September 26.

Dr. Trevor Wilkes Contributes to The Journal of Bone & Joint Surgery CME Program Dr. Trevor Wilkes, of Lexington Clinic Orthopedics - Sports Medicine Center, has served as the associate editor and content provider for The Journal of Bone & Joint Surgery Continuing Medical Education program. Dr. Wilkes provided the testing content in his area of specialty - Shoulder and Elbow Pathology and Surgery - and worked with colleagues from around the country to edit and produce the content for the 2018 program.

The Journal of Bone & Joint Surgery ( JBJS) has been the most valued source of information for orthopaedic surgeons and researchers worldwide for over 125 years and is the gold standard in peer-reviewed scientific information in the field.

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Fall 2018 • Kentucky

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6:30pm to 7:00pm: Dinner 7:00pm to 9:00pm: Dr. Dahle’s program Dr. Dahl, a practicing emergency physician and author of the best selling book, “The White Coat Investor,” and a popular personal finance blog site, has advice for his peers on personal finance and investing.

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Fall 2018 • Kentucky

PROSTHETICS

Hi-Tech Artificial Limbs When a new amputee is tasked with getting back to their life after losing a part of their body, it involves more than simply creating a prosthetic device to surrogate what was lost. The process is a deeply personal and psychological journey that involves a lot of community, love, and support. Hi-Tech Artificial Limbs, Inc. is a local company that understands the many facets of this journey. Founded in 1990 by Jim McClanahan and Maurice Adkins, the company has grown since that time and has come to be known as an indispensable resource for amputees. While the founders have passed on, Hi-Tech continues with its service to the area, helmed by Jim’s wife, Tori, and Maurice’s son, Shayne.

“The field of Prosthetics has changed a lot since we first opened,” explains Shayne, who is the Clinical Director and President of the company. “Technology is constantly evolving, which is exciting, but there are also many changes in the process of getting a patient the prosthesis they need. It used to be that a patient would simply come to the office with a prescription from their physician for a prosthesis, but now that process is very involved. Insurance requires a great deal of paperwork from both the physician and the prosthetist.

The medical necessity of the prosthesis has to be justified in the physician’s and prosthetist’s evaluations. Everything needs to be considered. Job, health, limb length, cognitive abilities, what did life look like for you before you lost your limb? All of this goes back to the physician’s documentation and there is a lot of back and forth between us and the doctors to show proper medical justification.”

Tori explains, “For the most part, insurance covers prosthetics, but sometimes it can be tricky. New items come to market all the time that insurance won’t initially pay for, but that would really help an amputee get back as close to normal as possible. The C-Leg is a good example of a technology that allowed above-the-knee amputees to go up and down stairs, foot over foot. The

microprocessor in the C-Leg allows the knee to react instantaneously, records the gait data and repeats it. They even make a military grade C-Leg for veterans who want to go back into service. While there is an insurance code for the knee, and even after Medicare coded and approved it, many insurance companies still fail to. We have learned to thoroughly evaluate exactly what a person needs for ambulation, depending on the individual. Some patients are more ambulatory than others.” Documentation in both the physcian and prosthetist medical records for a patient are considered in approving a prosthesis for a patient.

Sometimes amputees come to Hi-Tech with a script soon after amputation, others will come in by referral months after.

Sometimes they leave the hospital with no talk of prosthetics, as a chasm exists at times between amputation and the start of prosthetic care. “We’ve been trying to close that gap so the amputee can have the best outcomes possible,” says Shayne.

“Many times it can be helpful to start prosthetic care even before amputation, educating patients about the journey they will take. Early intervention allows us to educate the new amputee on the upcoming process. It also allows us the opportunity to teach the amputee how to use massage, desensitization techniques and fit them with compression garments “shrinkers” to begin shaping the limb, remove edema and increase circulation.” Hi-Tech offers cost free pre-amputation consultations and visits.

Partnering with patients in their overall wellbeing is a key component to successful use of their prosthesis. “We have experienced amputee patients who are more than willing to talk with newer amputees. Talking with other amputees who have led successful lives is incredibly empowering,” Shayne states.

Hi-Tech Artificial Limbs takes a very hands-on approach to helping patients navigate this process. “We are unique,” says Shayne, who is also a Certified Prosthetist.

“We have three board-certified prosthetic assistants and technicians. We have our

own lab in our facility and we do all of our fittings here. We don’t send anything off to be manufactured off site.” This allows Hi-Tech to be involved with the prosthesis from start to finish, as many times adjustments need to be made. With new amputees especially, a period of adjustment ensues in the months following surgery, as the patient’s limb changes.

Hi-Tech Artificial Limbs is built on the premise that relationships with the amputee are as important as the prosthesis. We celebrate patients’ birthdays here. We are like a family. Amputees need to feel like they have a place to go that feels like home with good people who have had relative experiences. The field of prosthetics is constantly changing and the staff at Hi-Tech believes in partnering with the patient to navigate their journey and investing the time needed to celebrate with them in their success.

For more info on Hi-Tech, please call (859)278-2389 or visit https://www. hi-techartlimbs.com.

859.278.2389 1641 Nicholasville Road, Lexington, KY 40503 M-Th 8am–4:30pm, F 8am–3pm

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Your Family, Your Health, Our Passion Family Practice Associates of Lexington, P.S.C. Proudly serving Kentucky for 35 years.

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PAIN TREATMENT

"I work with the patient to find solutions to more effectively manage that pain. " – MARIE SIMPSON,

Licensed Clinical Social Worker (LCSW)

The Effects Of Chronic Pain On Mental Health People frequently think that pain is a purely physical sensation. However, pain has biological, psychological and emotional factors. Pain can cause feelings such as anger, disappointment, hopelessness, sadness and fear, to name a few. “While medical treatments, such as surgical interventions, physical therapy/rehabilitation, and medications, can be helpful in treating chronic pain, psychological treatments are also very important,” says Heather Wright, CEO of The Pain Treatment Center of the Bluegrass. Understanding and managing the thoughts, emotions and behaviors that accompany the discomfort can help the patient cope more effectively with the pain.

At The Pain Treatment Center of the Bluegrass, the Behavioral Medicine Specialists work with patients to teach them how to cope with the feelings and behaviors that accompany chronic pain. “For patients dealing with chronic pain, I talk with them and show them new ways to think about pain. I work with the patient to find solutions to more effectively manage that pain,” says Marie Simpson, a Licensed Clinical Social Worker (LCSW) at the Center. Treatment plans are designed for each individual and may include developing relaxation techniques, changing old beliefs about pain, building new coping skills and addressing any

anxiety or depression that may accompany chronic pain. Kellie Dryden, another LCSW at the Center, explains: “We evaluate all patients who are referred to Behavioral Medicine to assess their presenting problems, mental health history, coping skills, interpersonal relationships, access to resources, and environmental factors that may impact the way they experience chronic pain. We also offer ongoing therapy sessions that can be scheduled the same day as their pain management office visits for those who travel long distances to continue to build on coping skills, offer support and make the best use of the patient’s visit to our Center.” Marie Simpson, LCSW, stresses that “most patients find they can better manage their pain with just a few sessions.”

While many health care providers work independently, not so at The Pain Treatment Center of the Bluegrass. Heather Wright, CEO highlights that “the Center employs providers from all specialties, who act together to ultimately give the best care possible to the patient. New patients are assessed by an array of professionals, including Board Certified Pain Specialists, Behavioral Medicine Specialists and Physical Therapist; all coordinating their efforts with the best and most current information from their particular disciplines.”

According to the National Institute of Mental Health, 2015, rates of depressive disorders ranged from 23% to 78% in chronic pain groups compared with rates of 5% to 17.1% in the general population.

“These statistics emphasize the need for a comprehensive approach to pain management,” stresses Heather Wright, CEO, “and we provide that at The Pain Treatment Center of the Bluegrass.” By doing so, The Pain Treatment Center of the Bluegrass helps its patients to more effectively manage both the physical and emotional sides of chronic pain.

For more information on Behavioral Medicine (ext. 285) and other services (ext.

258) at The Pain Treatment Center of the Bluegrass, call (859)278-1316.

Ballard Wright, MD, PSC 2416 Regency Road Lexington, Kentucky 40503 www.pain-ptc.com 859.278.1316

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