September 2017

SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y

ADDICTION AN OFFICIAL EMERGENCY

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VOL.90 NO.7 September 2017

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE September 2017 Volume 90, Number 7

ADDICTION: AN OFFICIAL EMERGENCY From the San Francisco Addiction Summit/David E. Smith, MD, Symposium

FEATURE ARTICLES

MONTHLY COLUMNS

12 The Only Way Forward? Medicalization of the Opioid Epidemic

4

Membership Matters

7

Executive Memo Mary Lou Licwinko, JD, MHSA

David E. Smith, MD, and Barbara Saunders

14 Addiction Treatment: Twenty-Five Years

David Pating, MD

15 Economic Burden: San Francisco Alcohol Consumption

By Tomás J. Aragón, MD, DrPH 16 Substance Use in America: Federal Responses

H. Westley Clark, MD, JD, MPH, and Matthew Davis

18 Facing Addiction in America: A Huge Opportunity to Move Our Field Forward

Constance Weisner, DrPH, MSA 20 Who You Gonna Call?: Addiction Medicine Workforce Development Scott Steiger, MD, and Paula J. Lum, MD, MPH

22 Addiction Medicine: The Role of Primary Care Providers Diana Coffa, MD 23 Alcohol Use: Dramatic Increases, Abuse Reported in

U.S. Adults

Salynn Boyles

24 The Empire Strikes Back (Again): San Francisco’s Prohibition on Sales of Flavored Tobacco Products Tanner D. Wakefield, BA, and Stanton A. Glantz, PhD 26 Allies for Change: Specializing in Pain Management and Sustainable Recovery Terrie M. Carpenter, PT, and Michael V. Genovese, MD, JD 28 Safety First: Drug Education in the Modern World Marsha Rosenbaum, PhD

9

President’s Message Man-Kit Leung, MD

11 Editorial

Gordon Fung, MD, and Steve Heilig, MPH 32 Medical Community News 34 Upcoming Events 33 Classifieds

OF INTEREST 6 Hibakusha (A-Bomb Survivor) Jack M. Dairiki

30 Health Policy Perspective: SFMMS Supports Supervised Injection Centers Pilot 31 San Francisco Department of Public Health:

Mumps and Pertussis: Vaccine-Preventable But

Still a Concern Dr. Eric Tang Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

SAN FRANCISCO

MARIN MEDICAL SOCIETY

SAVE THE DATE: SFMMS 150th Anniversary Celebration & Gala March 15, 2018 | St. Francis Yacht Club, San Francisco, CA In 2018, SFMMS will celebrate its 150th Anniversary. Save the date for a celebration not to be missed! More information and registration will be available soon at https://www.sfmms.org/events.aspx. Sponsorship opportunities available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members

SFMMS Summer Social and Art Gallery Tour Provided Exclusive inside Look into Artists’ Studios

More than twenty members attended the SFMMS Summer Social in July. The event, co-sponsored by Mercer, started with an introduction from Daylighted, a company that specializes in bringing art into public spaces, about the value of supporting the local arts. The evening continued with exclusive access to three private artists’ studios. Attendees enjoyed the unique format of the event, and the opportunity to hear from the artists about the approach used for designing their work. Stay tuned for details of future member networking events, such as this!

Survey Shows Physicians Feel Unprepared for the Business Side of Medicine

A recent LinkedIn survey found that many physicians feel that their clinical training does not adequately prepare them for the reality of the business side of a career in medicine. The survey, conducted in early February, asked 511 physicians about their professional goals and the non-clinical skills that they believe are most essential to their careers. Three-quarters of respondents indicated that non-clinical business skills are more important than they were in the past because of how deeply and rapidly the health care industry is changing. More than twothirds said their career goals include better work-life balance.

Nearly half pointed to skills like business and finance, productivity and practice management as essential to take their career to the next level. For more details on the LinkedIn survey, and related commentary from physicians, visit http://bit.ly/2ulXGr7.

Physicians Apprehensive Regarding Requests for Provider Directory Information

CMA continues to receive inquiries from practices concerned about the validity of requests for payors to confirm physician demographic information. The requests are related to the 4

provider directory accuracy law that took effect on July 1, 2016 (SB 137), which requires physicians to respond to plan and insurer notifications regarding the accuracy of their provider directory information. Some payors may delegate the provider directory outreach efforts to a third party vendor. Practices are encouraged to respond to the information requests. Failure to do so may result in a delay in payment and removal from the provider directory. Additionally, a payor may terminate a contract with a provider for a pattern of repeated failure to update the required information in the directories. For more information about physicians’ obligations under the new law, see CMA’s resource, “What Physicians Need to Know to Avoid Penalties Under the New Provider Directory Accuracy Law” (http://bit. ly/2oUgpbk), as well as CMA On-Call document #7163, “Provider Directories” (http://bit.ly/2ulJVbO).

CMS Dedicates New Webpage to Medicare Beneficiary Identification Number Change

The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) requires the Centers for Medicare and Medicaid Services (CMS) to remove Social Security numbers from Medicare cards to prevent identity theft. CMS has said it will in 2018 begin issuing new Medicare cards that replace the current identification number—which is the beneficiary’s Social Security Number—with an all-new Medicare Beneficiary Identification (MBI) number. CMS has developed a new webpage (https://www.cms.gov/Medicare/ New-Medicare-Card/Providers/Providers.html) to help physicians navigate the transition to the new MBI number, including a recently developed resource on how to talk to your Medicare patients (http://go.cms.gov/2wEwS60) about the new Medicare card. Physicians should also talk to their practice managers and health information technology (IT) vendors now to ensure their systems will be ready to accept the MBI.

Survey Finds Nation’s Physicians Not Ready to Fulfill MACRA Reporting Requirements

Fewer than one in four physicians feel ready to meet the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) reporting requirements, according to a survey of one thousand physicians conducted by the American Medical Association (AMA). Over half of those surveyed (fiftysix percent) plan to participate in the Merit-based Incentive Payment System (MIPS) in 2017, which provides variable incentive payments or penalties based on certain quality and efficiency measures, while eighteen percent are expecting to qualify for higher and more stable payments as Advanced Alternative Payment Model (APM) participants. The survey also found that a majority (fifty-one percent) of physicians who are involved in

SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

practice decision-making feel somewhat knowledgeable about MACRA and the QPP, but only eight percent describe themselves as “deeply knowledgeable” about the program and its requirements. Additionally, ninety percent felt the reporting requirements were “somewhat” or “very” burdensome.

Read more at bit.ly/2uhPADe. To help physicians understand the payment reforms and prepare for the transition, SFMMS has a MACRA resources page at www.sfmms.org/for-physicians/macra-resources-for-physicians.aspx.

Learn How to Challenge the Interim Payment for Out-OfNetwork Services at In-Network Facilities

On July 1, 2017, a new law (AB 72) took effect that changes the billing practices of non-participating physicians providing covered, non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an outof-network doctor. The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges. However, it also includes mechanisms for physicians to challenge the interim payment. CMA has published a number of resources to help physicians navigate this new system, including a sample letter physicians can use to appeal to the plan/insurer and an FAQ. These resources are available free to members only in our AB 72 Resource Center at www. cmanet.org/ab-72. CMA is also hosting a free members-only webinar on the different options for challenging the interim payment on September 27, 2017. Click here to register for the webinar: http://bit.ly/2vJOUqq.

UnitedHealthcare Plans to Discontinue Payment for Consultation Services

UnitedHealthcare (UHC) announced that it will no longer reimburse consultation services for commercial product lines effective October 1, 2017. Consultation services previously represented by Current Procedural Terminology (CPT) codes 99241-99245 and 99251-99255 will now need to be billed utilizing the appropriate evaluation and management (E/M) procedure code that describes the office visit, hospital care, nursing facility care, home service, or domiciliary/rest home care. The CMA, in conjunction with a number of other state medical societies, issued a letter to UHC (http://bit.ly/2vfChTg) expressing serious concerns regarding its decision to no longer pay for consultation codes. If you wish to voice concerns about the UHC policy change, please contact UHC Network Management or your assigned UHC Physician Advocate.

Has A Contracted Payor Stopped Paying Claims?

The CMA has recently received an increased number of calls from physicians reporting concerns that some of the entities with whom they contract may have run into financial difficulties. One of the symptoms of an insolvent health plan, Independent Practice Association (IPA), or other payor is the failure to pay claims in a timely manner. Another indication of financial distress is a payor that cuts checks within the statutory timeframes, but does not release the checks in a timely manner. If you are experiencing repeated payment delays, you should investigate the financial health of the payor.

To help physicians monitor the financial health of their contracted payors, CMA has put together a Payor Solvency Checklist (http://bit.ly/2vBAwRv).

The checklist, available free to members in the CMA Resource Library, includes instructions on how to research and monitor the financial solvency of your contracted medical groups/IPAs, and discusses options available to physicians in the event a payor stops paying claims.

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September 2017 Volume 90, Number 7 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD MMS Officers President Peter Bretan, MD President-Elect Michael Kwok, MD Secretary/Treasurer Naveen Kumar, MD Immediate Past President Jeffrey Stevenson, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Mina Yoo SFMMS BOARD OF DIRECTORS Larry Bedard, MD Charles E. Binkley, MD Peter Bretan, MD Irina deFischer, MD Nida Degesys, MD David T. Duong, MD Benjamin L. Franc, MD Steven H. Fugaro, MD Robert A. Harvey, MD Imran Junaid, MD Naveen Kumar, MD Michael Kwok, MD Raymond Liu, MD Todd A. May, MD Jason Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Ray Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD

Monique D. Schaulis, MD Michael C. Schrader, MD Lori Selleck, MD Dennis Song, MD Jeff Stevenson, MD Winnie Tong, MD Matt Willis, MD Joseph W. Woo, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

SEPTEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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Hibakusha (A-Bomb Survivor) Jack M. Dairiki

In Hiroshima City’s Atomic Peace Park, there is a poem carved into a rock which states, “Please rest in peace, for this error shall never be repeated.”

It is a pledge to all living people of the world to protect all of humanity.

I witnessed the holocaust three and one-half miles from the atomic bomb detonation point.

I traveled to Hiroshima, Japan in August 1941 with my father as a summer vacation to visit my ailing grandfather. Unfortunately, we were stranded there in September of that year.

Finding no passage to return to Sacramento, California, my father and I were separated from my mother and four siblings who were interned in the Tule Lake, California, Jerome and Rowher, Arkansas, and finally, the Amache, Colorado camps.

I, along with my classmates, were conscripted to work for the Japan War Effort (Gakuto Do In) at Toyo Factory. I was a 14-year-old student. We worked there from January 1945 until the atomic bomb was dropped on August 6. On that fateful day, because of air bombing raids, my commuter train to the Toyo Factory was delayed by fifteen minutes. That delay saved me and my classmates from being in Hiroshima City. We were taking roll call at 08:15 when the bomb was detonated.

We noticed three B-29 bombers traveling towards Hiroshima. It was shortly after that sighting that we experienced the horrific explosion of the first atomic bomb. First, a blinding flash and a horrific blast of wind that took out ninety-nine percent of the Toyo Factory windows. I felt my body being lifted by this wind. When I opened my eyes, I was in the midst of dust and smoke and could not see my hands. Then I heard a fellow student run toward the bomb shelter which was a few hundred yards away; the entrance was at a higher elevation.

Perhaps thirty seconds had elapsed. I looked back at Hiroshima and saw the monstrous fire column rising thousands of feet into the air. The whole city was on fire, covered in smoke and fire with no buildings to be seen.

An hour later we peeked out from the cave shelter and witnessed the first victim. A young woman walking with her arms extended—her ragged clothes hanging from her arms and her hair burned off. She was looking straight ahead and walked like a ghost. We noticed as she came closer that it was not burned clothes, but her skin hanging from her arms.

We were instructed to return home if we were able to walk. I boarded a ghost train with the paint burned off and windows shattered. Inside the train were many injured people asking for medical aid. I could not help them so I dismounted the train to walk home, a distance of ten miles. My grandmother welcomed me—she was scanning the horizon for my return. The house was not damaged, except all the sliding doors were down but unbroken.

There were fifty-five hospitals, two hundred doctors and 6

two thousand nurses in Hiroshima City before the bombing.

What remained were three hospitals, twenty doctors, and one hundred seventy nurses to help the wounded. There were eighty thousand people who died in the city and near me. I can never forget the image nor the smell of death.

Rennyo Shonin stated: “In the Buddha Dharma there is no such word as tomorrow; only the magnificent today. How grateful I am for this moment.” This awoke me to the fact that every split second of my life, I must live with gratitude. Each Nembutsu, each breath, each heartbeat is my gratitude. As long as I am alive, my thoughts are on the people who went before and are around me, guiding me. In Gassho, Namu Amida Butsu, Namu Amida Butsu, Namu Amida Butsu, Namu Amida Butsu, Namu Amida Butsu.

Jack Dairiki has been a devout member of the Buddhist Church of America (BCA) for many years and is now serving as a minister's assistant under Rev. Ron Kobata at the Buddhist Church of San Francisco. He was honored with a “Certificate of Special Congressional Recognition and Peace Award,” signed by Congresswoman Nancy Pelosi, awarded to him during the National Japanese American Historical Society of San Francisco’s event on May 3, 2015, for his activity in speaking about his experience and the movement for peace.

SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

EXECUTIVE MEMO Mary Lou Licwinko, JD, MHSA

Timely Visit From Hiroshima Medical Team In July of this year, the Hiroshima Prefectural Medical Association (HPMA) conducted its biennial tests on the atomic bomb survivors living in the Bay Area.

The HPMA team has been coming to San Francisco since 1977 and this year marked its twenty-first visit. The visit is hosted by the San Francisco Marin Medical Association, the sister association to HPMA, Friends of Hibakusha (the Japanese word for the survivors of the 1945 bombings of Hiroshima and Nagasaki) and St. Mary’s Medical Center.

Every two years one HPMA team visits San Francisco and Seattle to conduct medical exams on the survivors while another team visits Hawaii and Los Angeles. As much as these visits provide valuable information for research and teaching regarding the long-term effects of radiation exposure, it is also a mission of peace to remind the world of the devastating effects of nuclear weapons. Many of us who lived through the Cold War and the Cuban Missile Crisis remember the ever present fear of these weapons being unleashed again. Recent events in North Korea give us pause and make this biennial visit an even more potent reminder of the threat the world still faces from nuclear weapons.

Medical Team and Examinations

The medical team consists of seven HPMA physicians and four administrative staff from the state and county governments. The tests are conducted at St. Mary’s Medical Center and include blood sampling, chest x-rays and EKGs. Several months after the exams reports of the check-up are mailed to the survivors. A major purpose of the examinations is to relieve medical concerns of many of the A-bomb survivors as well as to explain the Japanese support system that includes medical expense benefits for the survivors. Physicians from Hiroshima are able to explain to participants their conditions in Japanese and particularly in the dialects of Hiroshima and Nagasaki. Outside of Japan, the United States is home to the second largest population of Hibakusha with the largest number residing in Korea. The average age of all of the Hibakusha is now 80 years old. Seventy two years after the bombings, the Hibakusha population is dwindling.

in total through its own program and those conducted for other organizations.

During the visit, HICARE held a seminar on the data findings from its research conducted with various hospitals and research institutions in Hiroshima. The seminar provided some of the results of the health check-ups from the aging A-bomb survivors as well as a history of the health exams in North America and an overview of the HICARE activities and training programs.

Some of the findings include an increase in Leukemia in the first ten years after exposure, with increases in other cancers coming later. The data also indicate that survivors do not experience higher rates of Alzheimer’s, vascular dementia or osteoporosis than the overall Japanese population. Tests have been conducted on the children of the survivors but thus far data do not show any particular health risks to this population.

Health professionals interested in applying for one of the training programs, ranging from one week to three months, were encourages to contact HICARE at hicare1991@hicare.jp.

Mary Lou Licwinko is Executive Director of the SFMMS.

21st Biennial Medical Mission Welcome Breakfast for the Japanese Medical Team Delegation Hosted by Dignity Health St. Mary’s Medical Center at Morrissey Hall on July 14, 2017

HICARE

Accompanying the Hiroshima Team this year was the Hiroshima International Council for the Health Care of the Radiation-Exposed (HICARE). Founded in 1991, HICARE offers training programs for medical personnel directly engaged in treatment of radiation-exposed individuals throughout the world. Thus far, HICARE has accepted about 360 medical professionals into its training program and trained about 1,300 WWW.SFMMS.ORG

SEPTEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

PRESIDENT’S MESSAGE Man-Kit Leung, MD

Transgender Discrimination in the Doctor’s Office: Our Patients Deserve Better I first met Mara in 2014 after she moved to San Francisco from Maine. She had just completed treatment for a serious illness and needed follow up by an otolaryngologist.

After performing a thorough examination, I let her know that everything looked normal. She released a big sigh of relief and, as some patients like to do, gave me a hug as she said, “Thank you, doctor.” Fortunately, over the past three years, she has continued to do well, and at each visit I get another hug and thanks.

What distinguishes Mara from most of my other patients is that she is openly transgender. (Despite being in San Francisco, my office in the heart of Chinatown is not frequented by many openly transgender patients.) Although I was aware that transgender individuals face significant social stigma, President Trump’s recent announcement banning transgender individuals from serving in any capacity in the United States military raised my awareness of the institutionalized discrimination that confront the transgender population. Unfortunately, this discrimination pervades even the healthcare setting. In fact, according to a 2011 survey by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, twenty-eight percent of transgender and gender non-conforming respondents were subjected to harassment in medical facilities and two percent were victims of violence in the doctor’s office. Consequently, twenty-eight percent of survey participants admitted to postponing medical care due to discrimination. In addition, nineteen percent of these respondents reported being refused medical care due to their transgender or gender non-conforming status. No one should feel unsafe or embarrassed to seek medical care; no one should be denied health care because of their gender identity. With the 1.4 million transgender Americans including nearly a quarter of a million transgender Californians in mind, I asked Mara what changes I could incorporate in my office to better serve transgender patients.

Would you mind telling me about yourself?

I was named Mark when I was born in the early 1950s. By the age of eight, I knew that I was different. When the movie The Christine Jorgensen Story came out, I knew that was who I was. At the age of twenty-three, I came out to my parents, who thought I was homosexual, which was illegal in Massachusetts at the time. They sent me to a therapist who wanted to shock my brain, and I fled to Maine. I became a hidden person. I was a high school teacher, met a woman, and had three kids, but I knew that when I retired I would transition. So, when I turned sixty, I started transitioning and moved out to San Francisco.

WWW.SFMMS.ORG

What advice would you give to doctors to improve the experience of transgender patients in their offices?

First would be clear communication with the front desk. Patients should be asked how they would like to be addressed when they check in. I remember once being called “Mark” as I was getting roomed, and thought “Oh, God.” You know me—I just got up and told the entire waiting room that I used to be a man. Second, please ask which pronoun they would prefer for you and your staff to use. It’s easy to ask.

Third, if you don’t know the answer to a specific question related to transgender health care, please make the effort to look it up. There was one time my doctor didn’t know whether I needed to get mammograms based on my estrogen levels. It’s ok to not know, but I told him that I hoped he had the answer at my next visit. Finally, please don’t ever say, “I couldn’t tell.” It’s insulting. I don’t want to blend in. I want people to accept me as a woman. I’m lucky that I have passing privilege—it’s not obvious that I am transgender. But I have friends who have large hands or shoulders like a quarterback or full back or whatever back who don’t have passing privilege.

What do you think of President Trump’s recent announcement regarding transgender individuals in the military?

I have a close transgender friend who was in the military for years and served several tours of duty in Afghanistan and other places. The announcement made her feel that she was “less than” others.

That’s how transgender people feel in general: “Less than.” We are less than a complete person, less of a citizen; we are nothing. That’s how the President’s announcement made me feel.

Would you mind if I used your real name?

You know me, Dr. Leung. I am proud of who I am. You can use my real name. I feel honored that you asked me for advice.

As our phone conversation ended, I told Mara that I was proud of her too and thanked her for her time and thoughts. I promised that I would make the recommended changes to my office and would try to spread her message to other doctors. I reminded her of her next appointment with me, at which time it would be my turn to say thanks and give her a hug.

Man-Kit Leung, MD, is an otolaryngologist—head and neck surgeon—in private practice and president of the San Francisco Marin Medical Society. He welcomes correspondence at mleung@ sfmms.org.

SEPTEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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MARIN GENERAL HOSPITAL CONSTRUCTION UPDATE

2020

5 Solariums/ Balconies

PRIVATE PATIENT ROOMS

171 6 New Operating Rooms

19.7

projected to open

ACRES OF LAND

Our New Hospital, by the Numbers.

4 2

535 million

$

260,000 square feet

levels towers

3

rooftop gardens

We’re building a new hospital you can count on.

Learn more at www.mgh2.org Our new hospital is underway, and we can’t wait to give Marin the state-of-the-art healing place our community deserves. On July 19, we hit a major milestone at our Topping Off Ceremony — the official placing of the last steel beam atop the new hospital structure. To keep up with the latest details, make sure you visit www.mgh2.org regularly.

We post frequent updates on construction and parking. What’s more, you can browse through renderings of the future hospital, watch our live cam, and take a video tour.

Call our MGH 2.0 Hotline 1-415-925-7470 or visit www.mgh2.org for more information.

EDITORIAL Gordon Fung, MD and Steve Heilig, MPH

Addiction As Chronic Emergency "Trump says opioid crisis is a national emergency, pledges more money and attention."

- Washington Post, Aug. 10 Many years ago, the American Medical Association, weighing all the medical and societal costs of substance abuse, declared it to be our nation's most serious public health problem. Others have concluded likewise, but it has taken a "hurricane" of opiod abuse, addiction, and overdose to really spark national attention.

Now we have one aspect of drug abuse declared a "national emergency." It remains to be seen what this might mean in practice, policy, funding, and so on. Hopefully the increased attention will be to the benefit of all, although more general cuts in public health and medical funding and a proposed resurgence of punitive, counterproductive "drug war" approaches favored by the current White House make optimism difficult. Drug abuse isn't like a flood or earthquake where the problems are acute and can be met with a sudden mass infusion of palliative resources. The disease of addiction is a chronic, progressive, relapsing condition, which can be compared to, say, diabetes in terms of the biological and behavioral factors at work. And it is complicated by legal implications, stigma, and worse. Patients—and clinicians—have been caught in the middle of a "war on drugs," imperatives to relieve both pain and drug abuse, and, in a broader sense, the vast, chronic social conditions that foster such abuse.

A local example of extreme problems warranting extreme measures, consider this recent SFMMS letter in the San Francisco Chronicle: Supervised injection centers may represent a concept that strikes some people as counterproductive. However, the same was said years ago about syringe exchange efforts, which have been shown to not only prevent transmission of harmful diseases, but also facilitate the entry of some drug users into treatment programs.

Thus the San Francisco Marin Medical Society Board of Directors, composed of physicians from many specialties throughout our two counties, has voted to endorse the concept and a trial of such efforts here. We feel that this too could work to both decrease the incidence of infectious diseases and help drug users access needed drug treatment. The opioid abuse epidemic is indeed a crisis, which requires every possible means of lessening it.

-Dr. Man-Kit Leung, President, San Francisco Marin Medical Society One chronic problem is a shortage of resources, including clinicians, to deal with addiction problems. It wasn't until last year that the American Board of Medical Specialties (ABMS) finally recognized Addiction Medicine as a subspecialty. The SFMMS and CMA were important actors in the long effort to achieve this, which will help with competency, privileges, reimbursement, and more.

The California Society of Addiction Medicine spearheaded the recWWW.SFMMS.ORG

ognition of addiction medicine; CSAM dates back to 1973, and was itself in part also sparked by San Francisco-based pioneers, such as David Smith MD, who founded the Haight-Ashbury Free Clinics, recently featured in JAMA for their 50th anniversary, as a new UCSF graduate.

When the United States Surgeon General released a report titled "Facing Addiction in America" in 2016, many in the field hoped that this might become a landmark document, as the similar 1964 report on tobacco proved to be. Time will tell. But locally, Dr. Smith and a small team began planning a June 2017 San Francisco conference, or "summit", on addiction issues.

The SFMMS, San Francisco Department of Public Health, UCSF Philip R. Lee Institute on Health Policy Studies, and California Academy of Family Physicians all joined in and the all-day meeting, co-chaired by Smith and Steve Heilig and also known as the 5th Annual David E. Smith MD Symposium, drew a full house to UCSF Mission Bay, This issue of San Francisco Marin Medicine largely presents summary articles from our conference. We are grateful to have both local and national leaders contributing here. The opioid epidemic was of course a focus of the meeting, but we made sure that ongoing problems with alcohol, tobacco, and other drugs were also addressed (cannabis, a focus of the previous year's Smith conference, was not a major topic this year, but is included in this journal, as multiple challenges regarding health impacts, policy, medical use, and prevention obviously continue).

Our national drug abuse problem is a chronic emergency.

We can't help but note that all of the aforementioned substances of use and abuse are legal ones. As countless observers from many professions and perspectives have long concluded, this is a public health problem, not a legal one, and the remedies are also. One such remedy might be contained to at least some degree in the slogan coined at UCSF by Dr. Smith a half century ago, and which became the guiding vision of his clinic: "Health care is a right, not a privilege."

Still something to think about.

Editor and cardiologist Gordon Fung, MD, PhD, is clinical professor of medicine at UCSF with a practice in consultative general clinical cardiology, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the nation’s first UCSF Asian Heart & Vascular Center located on the Mount Zion Campus. He is a former SFMMS President. Steve Heilig, MPH, is director of public health and education for the San Francisco Marin Medical Society.

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Medical Education

THE ONLY WAY FORWARD? Medicalization of the Opioid Epidemic David E. Smith, MD, and Barbara Saunders When the Haight Ashbury Free Medical Clinic began treating large numbers of heroin addicts in 1969, it was illegal for a physician to prescribe psychoactive medications to detoxify an addict in an outpatient medical setting. This prohibition began

with the Harrison Narcotics Act in 1914. Addicts were deemed criminals and their doctors parties to criminal activity. In 2017, the gold standard of addiction care is medically-assisted treatment (MAT) administered as a component of a comprehensive recovery program. Yet in the midst of a deadly opioid epidemic, outdated ideas still put up barriers to widespread adoption of this life-saving approach.

On July 31, 2017, a bipartisan panel asked President Trump to declare a national emergency to deal with the opioid epidemic, the New York Times reported.1 Identifying their request as the “first and most urgent recommendation,” the commission noted that opioids kill as many people every three weeks as died in the September 11, 2001 attacks. To follow the panel’s recommendation, the administration must take heed of discoveries in the discipline of addiction medicine, and of findings in the Surgeon General’s 2016 report on addiction, a broad review of evidence which identifies structural as well as cultural challenges to addressing the crisis.2 Forty years ago, opioids seemed to be the most promising tools in physicians’ struggle for ways to minimize the suffering of patients with chronic pain. A 1980 letter in the Journal of the American Medical Association advised that the newer opioids posed little risk for addiction.3 That conclusion was found to have originated in studies performed and interpreted by pharmaceutical manufacturers with conflicts of interest, but the letter has since been cited extensively as the basis for liberalizing prescribing practices.4 The rapid increase in opioid addiction can be partially attributed to those events.

Ironically, according to a review of the literature published in the Annals of Internal Medicine, “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dosedependent risk for serious harms.” 5 As a class, the opioids pose unique challenges to addicted people, their medical providers, and society. In contrast to some other types of drugs, opioids cause severe—and sometimes fatal—withdrawal symptoms when people stop using them.

Many people have become addicted to opioids legitimately prescribed by their doctors, especially when the opioids have been prescribed over extended periods of time to manage chronic pain. When they can no longer receive their prescriptions, they turn to street drugs like heroin to avoid withdrawal symptoms, including increased pain. During the same time period, very 12

strong, laboratory-made substances like fentanyl made their way onto the black market, increasing the risk of overdose. Unlike previous heroin use in the U.S., the nexus of spread is coming primarily out of the medical system.

The opioid epidemic highlights the limitations of a fragmented system of medical care that regards people with substance abuse disorders as separate from the general population.

First, the public understands substance abuse disorders primarily through the lens of moral or Twelve Step philosophy, which describes addiction as a spiritual disorder. American Society of Addiction Medicine (ASAM) and Like Minded Docs advocate for an understanding of addiction as a complex biomedical, psychological, and spiritual disorder.6,7 The oversimplification is shared by policy makers and even some medical providers.

Many people harbor the sentiment recently expressed by Secretary of Health and Human Services Tom Price, who said, “If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.” (Price’s spokesperson softened his statements after former Surgeon General Vivek Murthy strongly countered that assertion on his public Twitter feed.)

Second, the ongoing “war on drugs” gives primacy to the demands of criminalization, even when that impedes medicalization. The balance is difficult to strike. For example, prescription drug monitoring programs can help ameliorate the problems of overprescription by duped, dated, or dishonest doctors; however, arbitrary federal caps on the number of prescriptions each physician is allowed to write decreases the system’s capacity to deliver treatment.

Currently there is not enough existing medical capacity to deliver medically assisted treatment to the people who need it.

Reporting on a study published in the American Journal of Public Health, the Huffington Post reported, “Even if every certified doctor prescribed Suboxone [one of a handful of prescription medications approved by the FDA to treat opioid addiction] to a maximum number of patients, an estimated 1.2 million people addicted to opiates in 2012 could not have legally obtained Suboxone (if they sought treatment).”8 The key is to expand the pool of adequately trained physicians to prescribe Suboxone as part of medication-assisted treatment for the complex disease of addiction.

The rate of diagnosis exceeds the rate of treatment by a factor of eight.9 Third, specialty care for addiction and primary care are poorly integrated, even though the health implications of substance misuse are inextricable from general physical and mental health. Only ten percent of people with a substance abuse dis-

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order receive specialty care. Most who do receive it in rehabilitation facilities, with little involvement by general health care providers. The almost eight percent of the population who met diagnostic criteria for a substance use disorder for alcohol or illicit drugs and the one percent who met diagnostic criteria for both an alcohol and illicit drug use disorder are in the care of primary physicians—if they are getting care at all. It is critical to arm family physicians with the skills to identify patients and families affected by substance use disorders, understand the risks of prescribing opioids, make early interventions, and collaborate with addiction medicine specialists.

Finally, as Governor Roy Cooper (D - North Carolina), a member of the White House commission, remarked in a separate statement, the opioid epidemic cannot be effectively addressed in a vacuum. Rather, it will be necessary to “[make] sure all Americans have access to affordable health care, which includes mental health and substance abuse treatment.”

Dr. Smith founded the Haight Ashbury Free Clinics in 1967, inaugurating the principle of “Health Care is a Right, not a Privilege.” A Diplomate of the American Board of Addiction Medicine and past President of the American Society of Addiction Medicine (ASAM) and California Society of Addiction Medicine (CSAM), Dr. Smith is Chair, Addiction Medicine & MQAC, of Muir Wood Adolescent Family Services in Petaluma, California, a residential treatment center for teens with substance abuse and cooccurring disorders; Consulting Physician at North Bay Recovery Center; and Medical Director of Center Point, in San Rafael, California, a therapeutic community focused on those coming out of the criminal justice system. Barbara Saunders, Dr. Smith’s writing and research assistant, is a technical and health sciences writer. A fill list of references is available at www.sfmms.org.

A 'Vaccine For Addiction' Is No Simple Fix Richard Harris, National Public Radio It's always appealing to think that there could be an easy technical fix for a complicated and serious problem.

For example, wouldn't it be great to have a vaccine to prevent addiction?

"One of the things they're actually working on is a vaccine for addiction, which is an incredibly exciting prospect," said Dr. Tom Price, secretary of Health and Human Services.

But, as is so often the case, there's no quick fix on the horizon for an epidemic that is now killing more Americans than traffic accidents. Researchers have been working on vaccines against addictive drugs, including nicotine, cocaine and heroin, for almost two decades.

"Like any other vaccine, you inject the vaccine and you use your immune system to produce antibodies," says Dr. Ivan Montoya, acting director of the division of Therapeutics and Medical Consequences at the National Institute on Drug Abuse. "In this case, the antibodies are against the drugs of abuse." The trick would be getting your body to produce enough antibodies to soak up a surge of drug injected into the bloodstream.

That's apparently a major reason that previous attempts to make a nicotine vaccine for smokers failed, he says. "The second challenge is getting the person to be vaccinated on a regular basis." These vaccines aren't like the measles vaccine that you receive once or twice for a lifetime of immunity. Multiple shots per year would likely be required. So the strategy would only work in people who were actively trying to recover from a drug addiction.

Kim Janda, a professor of chemistry at the Scripps Research Institute, says he's thinking about developing a vaccine that targets both heroin and fentanyl. But his first priority is to test a heroin vaccine in people. So far, he's used funding from the National Institutes of Health to test his potential vaccine in rodents and monkeys.

He's optimistic that human tests could begin in eighteen months once he has funding, though it would take much longer than that to find out whether the vaccine is actually safe and effective.

Janda knows that a vaccine would supplement, rather than replace, the current approaches to treating addiction.

"I think we need to look at other ways of treating opioid addiction," he says, "and I think this can help."

From National Public Radio: full story: http://www.npr. org/sections/health-shots/2017/08/10/542605039/a-vaccine-for-addiction-is-no-simple-fix

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Medical Education

ADDICTION TREATMENT Twenty-Five Years David Pating, MD In 1985, the Exxon Valdez rammed the coast of Alaska, spilling tons of crude oil along miles of pristine shoreline. The captain of this oil-carrying behemoth was not on

deck due to sleeping off an alcoholic bender. Following this, local refineries awoke to the risk of a similar accident occurring in the San Francisco Bay. Imagine: “Drunken oil barge pilot hits Golden Gate Bridge!” Fearing such a catastrophe, refiners and local unions demanded that health insurers immediately expand coverage for substance abuse treatment.

With its historically close ties to unions and purchasers, Kaiser Permanente Northern California was among the industry’s first responders to fix substance abuse in the workplace. They invested five million dollars to expand addiction treatment in five geographical regions. By today’s dollars, this was not much despite representing a ten-fold increase in services. Treating addicts and alcoholics was considered an insurance gamble. Could drunken sailors, electricians or crane operators be taught new ways? Would enhanced substance use disorder (SUD) treatment reduce the risks of drug abuse or be a waste of money?

Committed to a deep dive, Kaiser strung together seventeen clinics to provide multiple levels of “all you can eat” outpatient, day hospital, and residential SUD treatment. Predating the National Institutes of Health’s Decade of the Brain, these services were state of the art—each of these clinics was embedded with psychiatric and medical services, providing a parity-level of care that eventually became the federally mandated standard.

As the nation’s first major private-sector expansion of SUD treatment, Kaiser attracted top-notch researchers to monitor the progress of their investment. Led by University of California, San Francisco’s Constance Weisner, LCSW, PhD, the Kaiser Drug and Alcohol Research Team (DART) proved beyond doubt: substance abuse treatment is both effective and wise health policy.

Here are six lessons learned from twenty-five years of innovation in addiction treatment:

Lesson 1. Addiction treatment saves money while saving lives!

Substance Use Disorders treatment improves the lives of patients at a bargain. Adding just pennies per month to overall healthcare costs, SUD services nearly return these costs within one year with reduced medical, Emergency Department (ED), and inpatient stays. Patients get better, their health improves. Everyone wins!

Lesson 2. Savings are particularly high for patients with co-occurring medical or mental disorders. Addicts with psychiatric comorbidity are among healthcare’s highest utilizers, especially of EDs and hospital services. When treated, the benefits are double.

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Lesson 3. Family members of substance abusers also have poor health. Yet, they too get better when the addict is treated. Drugs and alcohol affect not only addicts—the whole family is impacted!

Families of addicts have higher asthma, diabetes, obesity and hypertension. When the family addict is treated, the health of their partners, spouses, and families dramatically improves!

Lesson 4. Early interventions by Primary Care are beneficial beyond simply reducing alcohol use. Screening and brief intervention for substance abuse by Primary Care reduces the consequences of at-risk alcohol and drug use. With just simple advice to “cut back,” patients significantly reduce high blood pressure and hemoglobin A1C within one year. When combined with medications to reduce cravings for alcohol (e.g. naltrexone, topiramate), ED visits and hospitalizations are also reduced.

Lesson 5. Linkage to Primary Care following treatment doubles

long term outcomes. Patients receiving continuing care following substance abuse treatment are twice as like to remain sober at nine years (p<.0001) and less likely to go to ED or be hospitalized.

Lesson 6. Patients can provide important feedback about what’s

working to reduce drug and alcohol use. Listening to our patients through feedback informs care focused on self-reports of cravings, mood, relationships and life functioning, and improves retention in treatment. Patients will tell us when treatment is not working.

Taken individually, these lessons speak to practical means to reduce the health burden of addiction at work and home. These benefits extend beyond the patient and their family. With foresight and ample SUD services, we can avoid the impact of maritime drunkenness on our San Francisco Bay! David Pating, MD, is Chief of Addiction Medicine at Kaiser Medical Center, San Francisco. Pating is an Associate Clinical Professor at UCSF School of Medicine and site-director of the joint UCSF VAMC-Kaiser fellowship in Addiction Medicine. He is a past-president of the California Society of Addiction Medicine, a past-board member of the American Society of Addiction Medicine, and served as Vice-Chair of California’s Mental Health Services Oversight and Accountability Commission (Proposition 63). In 2014, he was appointed as a Health Commissioner for the City and County of San Francisco. He is an SFMMS board member and serves on the Editorial Board San Francisco Marin Medicine. A full list of references can be found at www.sfmms.org.

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Medical Education

ECONOMIC BURDEN San Francisco Alcohol Consumption

By Tomás J. Aragón, MD, DrPH In the United States, the large increase in alcohol use, high-risk drinking, and alcohol use disorder over the past fifteen years constitutes a public health crisis.1 An estimated 88,000 people die from alcohol-

related causes annually, making alcohol the fourth leading preventable cause of death in the United States.2 On August 9, 2017, the Journal of the American Medical Association (JAMA) reported that between 2001 and 2013 the “[s]ubstantial increases in alcohol use, high-risk drinking, and DSM-IV alcohol use disorder constitute a public health crisis and portend increases in chronic disease comorbidities in the United States . . .” Twelve-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder increased 11.2 percent, 29.9 percent, and 49.4 percent, respectively, for the total U.S. population and, with few exceptions, across sociodemographic subgroups. For adults under age thirty, nearly one in four (23.4 percent) met the criteria for alcohol use disorder.

Excessive alcohol use, especially binge drinking, has immediate effects that lead to numerous harmful health conditions, including (a) injuries from motor vehicle crashes, falls, drownings, and burns; (b) violence, including homicide, suicide, sexual assault, and intimate partner violence; (c) alcohol poisoning; (d) risky sexual behaviors resulting in unintended pregnancy or sexually transmitted infections, including HIV; and (e) miscarriage and stillbirth or fetal alcohol spectrum disorders among pregnant women.3 Over time, excessive alcohol use leads to chronic diseases and social problems, including (a) hypertension, heart disease, stroke, liver disease, and pancreatitis; (b) cancer of the breast, mouth, throat, esophagus, liver, and colon; (c) learning and memory problems, including dementia and poor school performance; (d) mental health problems, including depression and anxiety; (e) social problems, including lost work productivity, family problems (e.g., child neglect, etc.), and unemployment; and alcohol dependence, or alcoholism.3 Contrary to popular myths: alcohol’s beneficial health effects are minimal to none, based on two recent systematic reviews.4,5 After correcting for misclassification and selection biases, moderate alcohol consumption did not confer cardiovascular or all-cause mortality benefits. In a thirty-year followup study, alcohol consumption, even at moderate levels, was associated with adverse brain outcomes including hippocampal atrophy in a dose dependent fashion.6 There was no protective effect of light drinking over abstinence. Even if one believes that the health benefits of moderate alcohol use are valid, alcohol’s adverse effects far outweigh any small beneficial effect.

What are the economic costs of alcohol consumption? In the U.S., the annual cost of alcohol consumption is $249 billion WWW.SFMMS.ORG

($28.4 billion for health care; $179.1 billion for lost work productivity; and $41.6 billion for other costs (e.g., crime victim property damage, criminal justice corrections, alcohol-related crimes, violent and property crimes, motor vehicle crashes, fire losses, fetal alcohol syndrome).7 In California, the annual cost of alcohol consumption is $38.5 billion, or $2.44 per drink, compared to $2.05 per drink for the U.S. About 40% of the costs were born by government, and about 75% was attributed to binge drinking. 8 In the April, 2017 policy report to the San Francisco Board of Supervisors, the SF Budget and Legislative Analyst’s (BLA) Office estimated that alcohol consumption resulted in annual costs of $54.8 million to local government, $655.3 million from health and alcohol-related incidents, and about $1 billion impact on total quality-of-life.9 These estimates are consistent with state and national estimates. Unfortunately, because alcohol-related events are not routinely tracked, this report underestimates the true economic costs to San Francisco. The BLA Office recommends for consideration policy options to improve (a) data tracking of alcohol-related costs; (b) land use approvals affecting alcohol outlet density in low-income, high crime areas; and (c) strengthening existing ordinances.

What can we do? Know the facts and support local efforts to mitigate the harms of excessive alcohol use. Unfortunately, our perceptions of alcohol are shaped by pervasive alcohol industry advertising. Unlike the success of state-funded tobacco control programs, we have limited alcohol harm mitigation programs to (a) inform the public and providers on the actual harms, (b) counter industry social marketing messages that promote drinking alcohol, and (c) promote evidence-based strategies that reduce excessive alcohol use.

Dr. Aragón is the health officer of the City & County of San Francisco, and Director of the Population Health Division (PHD) at the SF Department of Public Health. As health officer, he exercises leadership and legal authority to protect and promote health. As PHD director, he direct public health services. His LinkedIn site is www. linkedin.com/in/taragonmd. A full list of references can be found at www.sfmms.org.

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Medical Education

SUBSTANCE USE IN AMERICA Federal Responses H. Westley Clark, MD, JD, MPH and Matthew Davis Drug and alcohol misuse, and their related disorders, are significant public health challenges which affect millions across the country and place tremendous burdens upon society at large. The United

States is facing a dire substance misuse problem, including the recent unprecedented opioid abuse epidemic. Rather than addressing these issues as chronic diseases, the health care system has often viewed them instead as moral failings.

In response to the substance use crisis, the Surgeon General released a first-ever report in the fall of 2016, entitled “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health” [“SG Report”]. The goal of the SG Report is to inform policymakers, health care professionals, and the general public about effective, practical, and sustainable strategies to address the misuse of alcohol and other psychoactive drugs.

The report is broken down into seven distinct chapters: an overview of the report, the neurobiology of substance misuse, prevention programs and policies, early intervention and treatment strategies, the various paths to recovery, the role of health care systems on recovery, and finally, the vision for recovery in the future, all from a public health perspective.

Each chapter of the SG Report explains in plain English the scientific and evidence-based findings. This report is an invaluable tool because it packs a plethora of information under one useful umbrella. By going to the Surgeon General’s website, each chapter can be downloaded separately and used accordingly (https://addiction.surgeongeneral.gov/).

In addition to the SG Report, there are other federal level approaches of interest. Two pieces of legislation are good examples. The Comprehensive Addiction and Recovery Act (CARA) of 2016 was signed into law on July 22, 2016. This law allowed for a number of improvements for the treatment of substance use disorders. It authorized federal grants to assist in the improvement of access to overdose treatment through the use of naloxone, along with increasing education of practitioners and pharmacists on how to properly dispense the medication in the event of an overdose. The law also authorized $103 million in federal grants for the Department of Justice to create an opioid abuse program for alternatives to incarceration. In addition, it authorized the Department of Health and Human Services (HHS) to grant state-run substance abuse agencies and local governments funding for the expansion of medication-assisted treatment of opioid use disorders, along with further improvement of and access to medication-assisted treatment programs.

These include improved treatment protocols for pregnant and post-partum women facing substance abuse issues. It also extended to eligible nurse practitioners and physician assistants the right to prescribe buprenorphine for the treatment of opioid 16

use disorder. Lastly, the law authorized the HHS to award states federal grants for properly addressing the unprecedented opioid epidemic this country has been facing for the last decade.

Although CARA authorized an estimated $181 million for a comprehensive treatment approach to address the opioid epidemic, it is only an authorization bill, which means that it did not make available any funds; it simply authorized them. However, this was still a valuable step forward in the containment of this nationwide epidemic.

The second piece of federal legislation of note was the 21st Century Cures Act (“the Cures Act”) which was signed into law on December 13th, 2016. This law provided for $1 billion in grants, over the course of two years, to aid states in preventing and treating opioid abuse through activities such as the improvement of prescription drug monitoring programs, training for health care providers, and expanded access to opioid treatment programs.

It also ensures accountability without increased burden upon the states. The Cures Act also includes several subdivisions with goals ranging from the strengthening of leadership and accountability, the ensuring of mental health and substance disorders prevention, treatment, and recovery, as well as the strengthening of mental health and substance abuse care for children and adolescents. Overall, the Cures Act creates an array of policy reforms that should greatly empower health care providers, and the community at large, to more effectively addresses the mental health and substance use crises facing this nation.

A third piece of federal legislation is more controversial.

The American Health Care Act (AHCA), which was passed by the House of Representatives on May 4, 2017, would repeal and replace the Affordable Care Act (ACA) should it become law; it would also drastically alter the health care system in place today, by cutting coverage for millions of Americans. Within one year of passage, fourteen million people would be uninsured, and within ten years, twenty-three million Americans would be without coverage. The AHCA would cut $834 billion in Medicaid benefits, culminating in fourteen million fewer Medicaid enrollees by 2026.

The AHCA would also allow states to opt out of the ACA’s Essential Health Benefits (EHB) and community rating requirements. For people living in states modifying the EHB, who used services provided by EHBs, out-of-pocket expenses for healthcare would substantially increase, discouraging the use of these services. The benefits likely to be excluded from modified EHBs include maternity care, mental health and substance abuse benefits, rehabilitative services, and pediatric dental benefits. Thus far, the Senate has not acted on the AHCA and failed to pass an alternative to the AHCA.

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President Trump’s substance abuse budget request for fiscal year 2018 calls for around $28 billion across all federal agencies for increased drug control programs. This would include drug trafficking efforts by the Justice Department and State Department, as well as substance use disorder programs by the Veterans Affairs and Health and Human Services departments. In the Presidents’ proposed budget, the Substance Abuse and Mental Health Services Administration (SAMHSA) would receive a $400 million decrease in funding from $4.3 billion to $3.9 billion, which would primarily come from cutbacks in mental health programs and grants. Yet, within the President’s budget proposal, $589 million in SAMHSA funding would be allocated to help fight the opioid epidemic via the measures already proposed with the Cures Act and CARA. However, even with these allocated funds, The President’s budget would reduce mental health funding by $252 million and substance abuse prevention by $73 million. Additional cuts of $73.6 million would occur in the Health Surveillance and Program Support areas.

When it comes to initiating change for the future of substance use disorder prevention, treatment and recovery, the SG Report is an ideal means for facilitating that change. By moving away from the harsh judgement of moral condemnation into the realms of neurobiology, trauma, and vulnerability, prevention can be enhanced, treatment facilitated and recovery promoted. Too often people are discouraged from seeking treatment as a result of discrimination and stigma. The SG Report lays the foundation for supporting those who enter treatment by addressing cultural and psychosocial barriers and by promoting the wealth of credible scientific and clinical evidence that prevention is possible, that treatment works, and that there are many pathways to recovery. While activities at the federal level are important, the activities in the general community and in the recovery community are the most important.

By using the SG Report to inform local action agendas, rational and reasonable community-based strategies can be enhanced.

H. Westley Clark, MD, JD, MPH, is the Dean’s Executive Professor of Public Health at Santa Clara University in Santa Clara, California. Prior to his current role, he was the Director of the Center for Substance Abuse Treatment in the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

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Medical Education

FACING ADDICTION IN AMERICA A Huge Opportunity to Move our Field Forward Constance Weisner, DrPH, MSW The first-ever Surgeon General’s Report on substance use disorders has tremendous potential to change the way substance use disorders are prevented and treated!1 It was commissioned to inform and

mobilize numerous stakeholders: individuals with problems, their families, health care and addiction providers, insurers, health systems, researchers, and policy makers. Although in many ways the opioid crisis provided momentum for the Report, it points out that other substance use and problems are also prevalent, especially alcohol disorders which remain highest. Other substances have also reached epidemic proportions over time, such as cocaine, with marijuana also a new concern, particularly for adolescents.

Substance use disorders affect 20.8 million Americans (almost 8 percent of the adolescent and adult population),2 a rate that is similar to diabetes, and more than 1.5 times the annual prevalence of all cancers combined. To date, because of the historical separation of addiction treatment from other health care, we have ignored the forty million Americans whose less severe, but problematic, use causes high rates of injury and creates or exacerbates many health problems. That group is responsible for $80 billion in health care costs, whereas the most severe, but smaller, group costs less: $40 billion/year.

As a society, we have not addressed substance use disorders comprehensively—and not as public health issues. They have not been treated as a health condition and part of mainstream health care. Substance use disorders are due to both neurological and environmental influences that can be reduced with interventions. Many evidence-based prevention and treatment interventions now exist.

The Report makes a substantive and positive case for action- we can reduce substance misuse if we better translate science for the public, improve and expand professional training, and implement science-based prevention and treatment.

This calls for action to:

• Update public health policies to increase access and quality of services.

• Develop and disseminate the science: biology, epidemiology, prevention, treatment.

• Educate the public: we have a public health problem, NOT a lifestyle issue.

• Implement evidence-based prevention and treatment: medications, psychosocial therapies, evidence-based, trained workforce.

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• Implement strategies to address the broader effects of substance use and misuse on the health and well-being of individuals and communities.

• Recognize effective community-based prevention programs and implement them widely.

An approach that is similar to prevention and disease management used for other health conditions3,4—one that addresses prevention and the full continuum of problems is called for.5,6 It includes primary care screening with interventions, medications, and referral to specialty treatment for severe problems, and after specialty treatment, referral back to primary care for ongoing monitoring. A challenge is getting patients to specialty care from primary care, as addiction treatment is not always available, and simply referring does not guarantee a successful transition. Improving this is critical because only about one in ten of the 23 million individuals who need addiction treatment receive it, although there are now multiple evidence-based behavioral, psychosocial treatments (described in the Report), as well as medication assisted treatments (MAT). Medications include naltrexone, acamprosate, and disulfiram for alcohol disorders; buprenorphine, methadone, and naltrexone for opioid disorders; as well as several medications for tobacco dependence.

Unfortunately, no FDA-approved medications for marijuana, cocaine, or methamphetamine use are yet available. Further challenges exist in transitioning individuals after specialty addiction treatment back to primary care for ongoing care for their health problems and continued monitoring for their substance use.

It is a priority for health systems to address substance-related health issues with the same sensitivity and care as other chronic health conditions, i.e., to promote primary prevention and use of evidence-based treatments, integration of prevention and treatment services, and strong ties with specialty treatment.

This requires working with payers to develop and implement comprehensive billing models and to implement health information technologies that promote efficiency and high quality care.

The Surgeon General’s Report provides recommendations for more comprehensively addressing substance use disorders.

It calls for a population, public health-based approach that addresses individual, environmental, and societal factors influencing substance misuse, and how policy can address quality of life issues for individuals and their families. But it also notes that prevention and treatment are excellent investments in terms of public health and economic outcomes. The yearly economic impact in 2015 was $249 billion for alcohol and $193 billion for illicit drug use and disorders. We spend far less in treatment

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and prevention, although multiple studies show that tax dollar investments in health care and in engaging people in treatment will reduce costs to society.1 This is a pivotal time for change. The Report provides a tremendous opportunity to mobilize, as did Surgeon General Reports for other health conditions, such as smoking. Effective strategies and services exist for the full spectrum of problems, ranging from self-change to mainstream health care to specialty treatment. We can prevent, screen, intervene early, and treat these disorders with medications and with behavioral change approaches. Full integration of the continuum of services for substance use disorders with the rest of health care will significantly improve the quality, effectiveness, and safety of all health care.

Constance Weisner, DrPH, MSW, is a Professor in the Department of Psychiatry, University of California, San Francisco, and the Associate Director, Behavioral Health, Aging, and Infectious Diseases at the Division of Research, Kaiser Permanente Northern California.

References: 1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS; November 2016.

2. Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey On Drug Use And Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.

3. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002;288(15):1909-1914.

4. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med 1997;127(12):1097-1102.

5. Chi FW, Parthasarathy S, Mertens JR, Weisner CM. Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care based model. Psychiatr Serv 2011;62(10):1194–2000.

6. Parthasarathy S, Chi FW, Mertens JR, Weisner C. The role of continuing care on 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program.

Med Care 2012;50(6):540–546.

Survey Finds Many Doctors Underprescribing Buprenorphine Partnership for Drugfree Kids, drugfree.org Doctors are underprescribing the opioid addiction medicine buprenorphine, according to a new survey of addiction specialists.

Buprenorphine can be used to treat opioid addiction in the privacy of a doctor’s office. Doctors who prescribe the medication must have a waiver allowing them to do so. Until recently, doctors with waivers could prescribe buprenorphine to one hundred patients. This year, the cap was raised to 275. More than half of the doctors with a waiver said they were not currently prescribing the buprenorphine to capacity, according to the survey, which was presented at the American Psychological Association annual meeting.

Doctors who have a waiver but are not using it to capacity said they regularly turn away one to three patients a month who approach them for buprenorphine treatment.

For more on buprenorphine, visit the U.S. Substance Abuse and Mental Health Services Administration.: https:// www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine.

SCHOLARSHIP SUPPORTS UCSF MEDICAL STUDENTS Hello, Dr. Fugaro (SFMMS Past-Predident) - I’m writing to thank you for wonderful support to UCSF and the CMA scholarship. My former colleague, Betsy Cardis, spoke highly of you and your leadership role in getting the scholarship fund established. I’m delighted to share with you a few updates about the fund: Since the CMA scholarship was officially established five years ago, eight students with financial need have been awarded. Re just two scholarship recipients from this past academic year: Abby Wang is a rising third-year student from San Jose, entering her clinical rotations with an open mind. She has an extensive background in teaching and mentoring, especially in a cross-cultural context, and hopes to advocate for underserved and non-native English speaking patients as a physician. Alexandra Rojek, also a rising third-year from Chicago, has been involved with the SFMMS, CMA and AMA on a health policy level and is interested in pursuing internal medicine.

Thank you again for your investment in the next generation of health leaders!

All the best, Rossitza Dillon, UCSF Development and Alumni Relations

WWW.SFMMS.ORG

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WHO YOU GONNA CALL? Addiction Medicine Workforce Development Scott Steiger, MD and Paula J. Lum, MD MPH The first-ever Surgeon General’s Report on Alcohol, Drugs, and Health shined a public light on the staggering gap between the nearly 20.5 million Americans suffering from a substance use disorder in 2015 and the ten percent that received treatment.2 This treatment gap is due in part to the stigma attached to the disease of addiction, which prevents affected persons from seeking help. Shame and fear of discrimination drove peer support groups to be Anonymous, and these groups reinforced the notion that our health care system didn’t give a damn. If anything, many patients believe that medical providers are the cause of the problem. One of the narrative tropes of the current crisis of opioid use in the United States is the irresponsible doctor “creating addicts” through his prescribing practices. Moreover, general health care settings—where people who use drugs are over-represented—have failed to adopt universal screening procedures to detect patients with or at risk of substance use disorders, and have traditionally referred patients away when their substance use problems have grown severe enough to be discovered. This outdated separation of addiction medicine from mainstream medical practice has served only to erect silos and deepen the disparity. We are left with a health professional workforce that is undertrained to deal effectively with substance-related problems and unprepared to meet the current need for an integrated health care response.

Simply put, the training of health care workers needs an overhaul. What does the Surgeon General’s Report recommend?1 The current science of prevention, treatment, and recovery should be included in the curricula of schools of dentistry, medicine, nursing, psychology, public health, and social work.2 The neurobiology of addiction and the skills to provide interprofessional team-based care to persons with substancerelated health issues should be taught across the career (i.e. internships, residencies, fellowships, board certification, continuing medical education).3 In addition, experts and non-specialists should be trained to address the sequelae and comorbidities of substance use, such as adverse drug reactions, intoxication and overdose, infectious complications, and co-occurring psychiatric conditions. In this context, we describe the educational efforts at our local institution to develop a new and larger, more diverse workforce with the skills to prevent, identify, and treat substance use disorders through integrated care delivery. 4 UCSF’s new Bridges medical school curriculum launched in 2016 and featured in the July/August issue of this magazine5 is an opportunity to expand the addiction medicine workforce.

Currently, all preclinical students receive foundational didactics on addiction, learn about structural determinants of health, meet a panel of patients in recovery, and complete a quality 20

improvement project in the Clinical Microsystems Clerkship.

One such student project at a primary care clinic doubled the rate of naloxone prescription to reverse opioid overdose among high-risk patients. In the Foundation 2 stage of Bridges, clinical medical students participate in a daylong addiction course that builds on prior knowledge, cases, and skills. In the Model SFGH Clerkship Program, a structured program based at San Francisco General Hospital (SFGH), third-year students focus on the care of underserved populations, manage a disproportionate number of persons with substance use disorders, and visit the Opiate Treatment Outpatient Program (OTOP) on the SFGH campus.

Third-year medical students in their medicine core clerkship at SFGH also may participate in a narrative reflection exercise about encounters with patients that use alcohol and other drugs.

For students wishing to take a deeper dive, fourth-year electives are offered either at the San Francisco Veteran’s Administration Medical Center (SFVAMC) in addiction psychiatry or a new SFGH elective that immerses students in the interprofessional and multidisciplinary treatment team at OTOP and exposes them to addiction research, other treatment venues, harm reduction programs, and peer support groups.

Graduate medical and nursing education programs at UCSF have had a major impact on trainees’ experience with patients who use alcohol and other drugs. Through four separate training grants from the Substance Abuse and Mental Health Administration (2008-2017), primary care resident physicians, nursing students, and clinical staff and faculty at the SFGH, Parnassus, and Mt. Zion campuses have received skills-based training in Screening, Brief Intervention and Referral to Treatment (SBIRT) and effective, patient-centered management of persons with substance use disorders.6 Trainees and trainers of these curricula have gone on to become clinical champions and educational leaders in the field of addiction medicine. Senior residents also may enroll in an elective developed with support from the Mt. Zion Health Fund. Here they gain additional hands-on exposure to evidence-based treatment services delivered at the San Francisco Department of Public Health’s Outpatient Buprenorphine Induction Clinic (OBIC) and Medical Respite & Sobering Center, the San Francisco AIDS Foundation’s syringe services and harm reduction programs, and cutting-edge addiction science at UCSF Drug Use Research Group seminars. Finally, we deliver a popular ASAM-sponsored buprenorphine waiver training course twice yearly, which satisfies federal training requirements for the office-based treatment of opioid use disorders. The course has been well attended by UCSF residents and faculty in emergency medicine, family medicine, internal medicine, obstetrics and gynecology, palliative care, pediatrics, and psychiatry, and by nurse practitioners and physician assistants.

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At the postdoctoral level, UCSF offers two one-year clinical fellowship programs: one in addiction psychiatry at the SFVAMC and a new primary care addiction medicine fellowship at SFGH. The former trains addiction psychiatrists at the SFVAMC, Kaiser, and private addiction treatment centers, with graduates moving on to leadership positions in public and private addiction treatment programs and organizations, such as the California Society of Addiction Medicine. The new addiction medicine fellowship prepares primary care physicians to become leaders in the care of persons with substance use disorders in the safety net communities of San Francisco (https://hiv.ucsf.edu/education/addiction-fellowship.html). With formal recognition of an Addiction Medicine specialty by the American Board of Medical Specialties in 2015, the foundation for this fellowship program is the integration of primary care, addiction medicine services, and harm reduction practice and policies for patients with health disparities from urban, low-income, and stigmatized populations.

Practicing physicians and other health care professionals will continue to be essential players in realizing the effective integration of behavioral health and general health care that is called for in the Surgeon General’s Report. To that end, we teach regularly about addiction at local CME courses sponsored by UCSF, the SFDPH, the Pacific AIDS Education and Training Center, the California Healthcare Foundation, and the California Society of Addiction Medicine. We welcome community providers to our buprenorphine waiver trainings, and we serve as course directors for similar trainings in rural California. The UCSF Clinician Consultation Center, in addition, offers a Substance Use Warmline (855-300-3595), which provides primary care clinicians free nationwide telephone consultation with addictionmedicine certified physicians, pharmacists and nurses (http:// nccc.ucsf.edu/clinical-resources/substance-use-resources/).

Our efforts to cultivate an addiction medicine workforce for the 21st century already are making an impact in San Francisco and beyond. We are emboldened by our patients in recovery and driven harder by our patients not yet engaged in integrated systems of care.

While a devastating epidemic of opioid use and overdose inspired the Surgeon General to issue this report in 2016, we predict more substance use epidemics in the future. However, because of the actions we take now to rebuild addiction medicine education across the country for all health care professionals, we will be better prepared to respond together with courage, science, and compassion. Who you gonna call?

Scott Steiger, MD, is Associate Clinical Professor of Medicine and Psychiatry at UCSF. He was appointed in 2012 to the UCSF Division of General Internal Medicine at the Mt. Zion campus, where he led quality improvement initiatives and teaching about opioid safety and substance use disorder while providing integrated primary care and addiction medicine services. Since 2016, Dr. Steiger has been Deputy Medical Director of the Opiate Treatment Outpatient Program and sees patients for primary care in the Division of General Internal Medicine at Zuckerberg San Francisco General. Paula J. Lum, MD MPH, FASAM is a primary care physician and Professor of Medicine in the Division of HIV, ID & Global Medicine at the University of California, San Francisco. Her clinical practice, teaching, and research focus on the health of persons WWW.SFMMS.ORG

from marginalized urban populations, especially persons who use drugs. She is board certified in internal medicine and ABAMcertified in addiction medicine. She also serves as the Program Director of the new UCSF Primary Care Addiction Medicine Fellowship, which prepares primary care physicians to become leaders in the care of persons with substance use disorders in the safety net communities of San Francisco. stance Abuse Treatment in the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

References: 1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016 2. Center for Behavioral Health Statistics and Quality.

(2016). Results from the 2015 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: SAMHSA. 3. See footnote 1. Or https://addiction.surgeongeneral.gov/ vision-future/stakeholder-suggestions/educators-and-academic-institutions 4. See footnote 1 5. SFMM, July/August 2017 6. Azari S, Ratanawongsa N, Hettema J, Cangelosi C, Tierney M, Coffa D, Shapiro B, Jain S, Hersh D, Manuel J, Ciccarone D, Lum PJ. MedEdPORTAL Publications; 2015. Curriculum available at https://www.mededportal.org/​publication/​10080

Stretching the Scope — Becoming Frontline Addiction-Medicine Providers "Today in the United States, another 91 people will die from an opioid overdose.5 Under the watchful eyes of physicians, many people survive their acute illnesses only to die in public restrooms, in private homes, or on the street. There are many inspiring examples of physicians and health care communities that have similarly stretched the scope of their practice, and lives have been saved as a result. We believe it’s time for more of us to join the movement."

Alison B. Rapoport, MD, and Christopher F. Rowley, MD N Engl J Med 2017; August 24, 2017

Reframing the Opioid Epidemic as a National Emergency "It may have taken years for this epidemic to reach crisis levels, but it could take only months for coordinated, bipartisan interventions across public and private sectors to take hold. Preventable deaths and injuries attributable to opioid misuse will never be acceptable, but the emergency should come to an end when opioid addiction and death rates return to historic lower levels."

Lawrence O. Gostin, JD; James G. Hodge Jr, JD, LLM; Sarah A. Noe, BA JAMA. August 23, 2017

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ADDICTION MEDICINE The Role of Primary Care Providers Diana Coffa, MD Even before the opioid crisis, primary care physicians, nurse practitioners, and physician assistants worked with patients with addiction on a daily basis. In every primary care practice, regardless of demograph-

ics, there are patients with substance use and alcohol use disorders. Whether or not they are identified and diagnosed, they are present in the practice and in need of assistance.

A small minority of people with substance use disorders (SUD) receive treatment. Many of those people present to primary care clinics but are never diagnosed, much less offered treatment. While it is critical that we increase access to specialty SUD treatment, it is at least as critical that we increase our primary care system’s capacity to identify patients with SUDs and help them make the transition into treatment.

Recognizing this, the Substance Abuse and Mental Health Services Administration has supported dissemination of the SBIRT (Screening, Brief Intervention, and Referral to Treatment) model of substance use management in primary care. In this model, primary care providers (PCP) screen every patient for SUD, provide brief, counseling for those who screen positive, and refer people to treatment if they meet diagnostic criteria for SUD and are amenable.

While early studies of the SBIRT model were promising, later studies of real-world implementation, particularly in nonalcohol drug use, had little success. There are many reasons for this, but one of them seems to be that a typical referral to treatment by a primary care provider, which often involves nothing more than giving the patient a phone number to call, has little influence on the patient’s probability of actually entering treatment.

At the same time, it has become increasingly clear that opioid use disorder and alcohol use disorder can sometimes be effectively treated in the primary care setting. Some studies have even suggested that buprenorphine for opioid use disorder may be more effective when provided in the primary care context.

This may be because patients’ engagement with care is shored up by their engagement with the healthcare provider around multiple health issues, or because of the longitudinal relationships that primary care providers build over the course of years with patients. It may be because many PCPs see entire families, obtaining useful collateral information and enhancing family support for recovery. It may also be because the stigma of attending primary care appointments is relatively low, reducing barriers to treatment. Whatever the reason, it is clear that some patients will choose to receive treatment in the primary care setting, and that this option works.

The SBIRT model, then, has evolved into what is now being called the STIR model: Screening, Treatment Initiation, and Re22

ferral. Turning the original model on its head, in the STIR model, primary care providers are encouraged to initiate treatment when possible, either with medications or counseling, and refer patients to the specialty addiction care when it is appropriate for the patient and the patient is ready to follow up the referral.

There are those who argue that addiction is outside the scope of primary care, often because they believe that addiction is not a disease like the other diseases we treat in primary care.

Addiction is thought to be too psychological or social in origin and not purely a biological illness. This argument reveals a fundamental misunderstanding of the nature of complex chronic disease. Take the analogy of diabetes. The development of and management of diabetes is strongly influenced by social factors, like neighborhood or friend group. It is influenced by cultural factors like preferred diet, by economic factors like food costs, by political forces like farm subsidies and school lunch policies, and by psychological and behavioral factors. Although diabetes definitely involves the pancreas and the insulin receptors, it is not purely a biological disease. This is exactly the kind of disease the PCPs specialize in. We specialize in managing complex, socially determined, interdependent chronic diseases. As a social, political, economic, psychological, behavioral and biological brain disease, addiction falls squarely within the scope of primary care. It requires exactly the skills that are developed by PCPs to manage other illnesses.

With the advent of the opioid crisis, for which there are very effective medications that can be prescribed in primary care, the role of the primary care provider in managing addiction has expanded substantially. As the opioid crisis unfolds and as we become increasingly aware of medications for the even more common illness of alcohol use disorder, it is clear that diagnosing and managing addiction has become a core competency of primary care providers.

Diana Coffa, MD, is a family physician and the director of the UCSF/ SFGH family medicine residency program. She is a site director for the UCSF Addiction Medicine fellowship and integrates the treatment of substance use disorders into her primary care practice. She has worked with the Substance Abuse and Mental Health Services Administration to develop national guidelines for the treatment of opioid use disorder in primary care and in parenting and pregnant women. A full list of references can be found at www.sfmms.org.

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Medical Education

ALCOHOL USE Dramatic Increases, Abuse Reported in U.S. Adults Salynn Boyles Alcohol use, high-risk drinking, and alcohol dependence all increased dramatically in the United States from 2002 to 2013, researchers reported, with spikes in overall drinking and problem drinking highest among women, the elderly, and minorities. Authors of the study, published in JAMA Psychiatry, de-

scribed the increases as "unprecedented" and warned that they constitute a public health crisis currently overshadowed by the focus on other abused substances.

"These are the largest alcohol increases we have seen in three decades," lead author Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism, told MedPage Today. "The focus has been on opioids, heroin, and marijuana use, but these are low prevalent disorders. Thirty million Americans now abuse alcohol."

Grant and colleagues compared data from two editions of the National Epidemiologic Survey of Alcohol and Related Conditions—one covering 2001-2002 and the other 2012-2013— which track alcohol consumption patterns to identify changes in twelve-month alcohol use, twelve-month high-risk drinking, and twelve-month alcohol use disorder (AUD).

High-risk drinking was defined as four or more standard drinks on any day for women and five or more on any day for men, and exceeding these daily drinking limits at least weekly during the past twelve months.

Alcohol use disorder as defined under DSM-IV criteria was used in the study because, although superseded in DSM-5, it was the recognized diagnosis when the surveys were conducted.

The survey data comparison revealed that:

• Alcohol use in the U.S. grew from 65.4% in 2001-2002 to 72.7% in 2012-2013.

• High risk drinking grew from 9.7% of the adult population (20.2 million Americans) in 2001-2012 to 12.6% (29.6 million Americans) in 2012-2013.

• DMS-IV diagnosis of AUD prevalence was 8.5% of the total adult population (17.6 million people) in 2001-2002 and 12.7% (29.9 million people) in 2012-2013.

• Prevalence of high-risk drinking and AUD among women rose 57.9% and 83.7%, respectively, during the study period.

• Among men, prevalence of high-risk drinking and AUD increased 15.5% and 34.7%, respectively.

The researchers called these increases "alarming" and said the same of highly significant increases in alcohol use and abuse among the elderly and racial and ethnic minorities.

Prevalence of alcohol use among adults who were ages sixty-five and older increased by 22.4% between the two surveys, WWW.SFMMS.ORG

while high-risk drinking and AUD among the elderly increased by 106.7% and 61.9%, respectively.

And between 2001-2002 and 2012-2013, there was a 92.8% increase in AUD prevalence among African Americans and a 65.9% increase among people reporting incomes of less than twenty thousand dollars.

Marc Schuckit, MD, of the University of California San Diego, noted that the elderly and the poor are especially vulnerable to the effects of alcohol abuse.

"I am especially concerned about the 106% increase in AUDs for older individuals because they are likely to carry multiple preexisting medical disorders that can be exacerbated by heavier drinking," he wrote.

He added that proposed cuts to the National Institutes of Health budget would be "potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all."

"Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere," he wrote. "If the proposed budget prevails, the National Institutes of Health will have serious problems keeping current research going, and it will be difficult or even impossible to fund new research."

Grant noted that alcohol dependence is still widely stigmatized and undertreated in the United States, far more than other mental health disorders.

"The treatment of major depression has been destigmatized, and as a result treatment rates are now around 60%," she said. "That compares to treatment rates of around 20% for alcohol (dependence), which is ridiculously low."

Study co-author Deborah Hasin, PhD, of Columbia University in New York City, said the study findings highlight the urgent need for increasing access to alcohol treatment in the U.S. "Most people do not seek treatment for alcohol abuse, and for those who do it is very hard to get," she told MedPage Today.

"There is also a common misperception that treatment is not very effective for alcohol disorders, but, in fact, it can be very effective."

From MedPage Today: https://www.medpagetoday.com/ Psychiatry/Addictions/67159?xid=nl_mpt_DHE_2017-0810&eun=g486176d0r&pos=2

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THE EMPIRE STRIKES BACK (AGAIN) San Francisco’s Prohibition on Sales of Flavored Tobacco Products Tanner D. Wakefield, BA and Stanton A. Glantz, PhD San Francisco made history in July when it adopted Supervisor Malia Cohen’s ordinance to prohibit the sale of all flavored tobacco products, including menthol, in the city. While laws putting some restrictions

on flavored tobacco product sales were on the books in other communities, San Francisco’s was the strongest to date.1 Shortly after Mayor Ed Lee signed the ordinance into law on July 7, 2017 2, Let’s Be Real San Francisco, “a coalition of concerned citizens supporting freedom of choice, adult consumers, community leaders, and neighborhood small businesses” appeared out of nowhere and started gathering signatures to force a referendum (popular vote at an election) on the law. 3 Let’s Be Real San Francisco’s press releases and statements claim it is a “local” effort, 4,5 North Carolina-based RJ Reynolds Tobacco solely financed the effort to the tune of $685,171 (as of July 31, 2017).6 (RJ Reynolds sells Newport cigarettes, the bestselling menthol brand and second biggest overall brand in the United States.7) Let’s Be Real’s principal officer is David Spross of Winston-Salem, North Carolina,8 RJ Reynolds’ Vice President of State Government Relations 9 and the treasurer Jason Kaune and assistant treasurer Joel Aurora are both attorneys at Nielsen Merksamer,8,10 the law firm that represents RJ Reynolds and Altria (which owns Philip Morris) and has helped run tobacco industry political campaigns in California since at least 1978.11 Kaune is not even a San Francisco resident, and is attacking a flavor ban protecting minors while serving as Vice President of the Board of Trustees at the Orinda Union School District.12 Using paid signature collectors, the committee easily collected the needed 19,040 valid signatures to force a vote on the June 5, 2018 election. The ordinance, which was to go into effect 2 months earlier, was suspended until that vote.

In forcing a referendum, the tobacco industry is reprising a strategy that failed in 1983, when Washington DC-based Tobacco Institute (then big cigarette companies’ political arm) hired Vigo Nielsen (the Nielsen at Nielsen Merskamer) to form San Franciscans Against Government Intrusion (SFAGI) to force a referendum on San Francisco’s new clean indoor air law that restricted smoking in workplaces and public places.13 Then, as in 2017, the big tobacco companies sought to shift the decisionmaking venue away from grass-roots politics, where public health forces are strong, to an election (advertising campaign) where big money talks louder.11,14 Referenda on city laws are rare. Proposition P, the industry’s failed 1983 effort was only the third referendum in San Francisco history (with earlier ones in 1937 and 1950) and there have only been 7 others since then.

In 2017, as in 1983, the cigarette companies hid in the shadows. The Let’s Be Real press conference featured local 24

businesses and e-cigarette advocates (including several flown in from out of town). The nationwide Smoke-Free Alternatives Trade Association, an e-cigarette advocacy group, endorsed “Let’s Be Real” and asked businesses to support the committee to “demonstrat[e] it is not just ‘big tobacco’ that wants this [ordinance] repealed in San Francisco.”15 However, as the big cigarette companies have entered the e-cigarette business they have increasingly dominated e-cigarette policy debates using their political clout and money, including links to pro-business think tanks.16 Speakers at the press conference outside City Hall on July 31, 2017,7,17 when Let’s Be Real announced that they had the needed signatures, featured people from the local business community, e-cigarette organizations, and the R-Street Institute think tank. Speakers mostly talked about the alleged value of ecigarettes for smoking cessation and echoing the same themes that the cigarette companies raised in 1983 (Table), freedom, crime, and economic harm. RJ Reynolds was nowhere to be seen and the speakers ignored the issues leading to the ordinance in the first place, notably the use of flavors and menthol to target youth18, 19 and minority groups, particularly African Americans.

20,21

Unlike 1983, health advocates did not need to convince the public and media that Big Tobacco is behind the 2017 effort.

Thanks to California’s strong campaign disclosure laws, the full name of the referendum committee is “Let’s Be Real San Francisco, A Coalition of Concerned Citizens Supporting Freedom of Choice, Adult Consumers, Community Leaders, and Neighborhood Small Businesses with Major Funding by R.J. Reynolds.”3 In 1983 health advocates managed to raise the $125,000 needed to successfully defend San Francisco’s clean indoor air ordinance against Big Tobacco’s $1 million campaign. 11 The Surgeon General found that the victory “attracted widespread publicity and stimulated further action” on local legislation.22 The tobacco industry’s pursuit of a referendum against the new flavor and menthol sales ban indicated that it again views San Francisco’s ordinance as a potential turning point in tobacco control. As of August 2017, Berkeley, Oakland, St. Paul, and Minneapolis had or were on the verge of adopting restrictions on sales of flavored and menthol tobacco products. Unlike 1983, the national health community recognized the importance of the San Francisco fight. The same day as Let’s Be Real held its press conference, the African American Tobacco Control Leadership Council, American Cancer Society Cancer Action Network, American Heart Association, American Lung Association, Americans for Nonsmokers’ Rights, Breathe California, and Tobacco-Free Kids Action Fund’s No More Flavored Tobacco Coalition23 issued a statement defending the restrictions on flavored tobacco products.24

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If the organizations that support the San Francisco ordinance commit the resources for San Francisco to beat back Big Tobacco San Franciscoâ&#x20AC;&#x2122;s action will again be another turning point in tobacco control, this time on flavors and menthol.22

FUNDING: This work was funded in part by the National Institute of Drug Abuse grant R01DA043950 and the William Cahan Endowment from the Flight Attendant Medical Research Institute to Dr. Glantz. The funding agencies played no role in the conduct of the research or preparation of the manuscript.

Tanner Wakefield is an Assistant Specialist at the University of California, San Francisco Center for Tobacco Control Research and Education. His areas of interest include industry interference in public health regulation and legislative advocacy by health forces to secure public health policies. Stanton Glantz is Professor of Medicine and Director of the Center for Tobacco Control Research and Education at the University of California San Francisco where he conducts research on a wide range of tobacco control topics, from health effects of secondhand smoke to the tobacco policymaking process. A full list of references can be found at www.sfmms.org.

CMA ADVOCACY PAYS OFF FOR TOBACCO TAX FUNDING From the California Medical Association

Arguments Harms Small Businesses

Penalizes Businesses for Customer Behavior Government Overreach Restricts Personal Freedom Creates a Black Market Exempts Government from Regulation WWW.SFMMS.ORG

Letâ&#x20AC;&#x2122;s Be Real 2017

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SFAGI 1983

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ALLIES FOR CHANGE Specializing in Pain Management and Sustainable Recovery Terrie M. Carpenter, PT and Michael V. Genovese, MD, JD Three weeks ago, a young woman came to my office in excruciating cervical pain: eight-to-ten out of ten and with markedly decreased mobility in her neck, shoulders, and entire body. She had been suffering with

this pain for over five years. She had gone from a very active, athletic, high functioning life to one of everyday suffering and decline. She was unable to work, had become addicted to opiates, gained fifty pounds, and been to numerous practitioners and suffered numerous invasive procedures. Her last procedure, an ablation, had resulted in a major increase in her pain and decrease in her function.

She was finally able to get help detoxing off of her drugs and then she was admitted to one of the local drug and alcohol residential programs. I consult with this program and they referred her to me.

NOTE: To support a client in the detox process it is best if their medications are decreased as the non-medication pain management strategies that will replace those drugs are taught and implemented.

Three weeks later . . . her pain is generally zero-to-two out of ten, her mobility has increased eighty percent, she has returned to activities such as swimming, walking and light gym workouts, and she is planning her future, a future that will not be dictated or controlled by pain. This young woman's story is typical for the people who come to us for help.

More than one hundred million Americans suffer from chronic pain at a cost of over six hundred billion dollars a year in medical treatments and lost productivity, according to a report from the Institute of Medicine (IOM) June 2011. Add to those numbers the family systems that have been affected and the number of sufferers becomes unimaginable.

The current frontline treatment for chronic pain is most often limited to:

One of leading reasons this epidemic has occurred is that no alternative to drugs and procedures have been offered to these individuals and their families. This approach needs to change.

As professionals we must learn to empower those individuals who come to us for help to:

• Become active participants in their healing process • Become proactive partners in their care • Understand that “if I have pain it is a signal from my body to change something and take good care of myself.”

We must extend to each one of these individuals the healing power of hope. We must support these individuals with compassion, education, and by offering effective non-medication strategies for healing.

That is exactly what we have done at Allies for Change. Our methodologies have been developed over several decades of clinical experience and include what I have learned from studying behavioral change at a very deep level.

I was recently invited to speak at the 5th annual David Smith Symposium, which focused on the opioid epidemic. I was grateful to have this opportunity because as speakers detailed the specifics and grand proportions of the opioid epidemic, I was able to introduce the audience to a different paradigm that is a non-medication model for helping individuals heal from chronic pain. Our model is simple but profound!

We work from a re-defined definition of chronic pain that has as its foundation the importance of evaluating the whole persona and all of the factors contributing to their pain complex. This model of thinking opens up a world of possibilities for care and gives clinicians a blueprint for how to effectively help individuals heal from this debilitating condition.

• Prescribing opiates, which can lead to addiction/dysregulation of an individual’s entire physiology and life; and • Performance of invasive procedures/surgeries, which can lead to weakened structures in the body and worsening of the soft tissue imbalance.

These treatment options have created legions of sufferers who have been trained to:

• To be passive recipients of treatment • Expect someone or some substance to be a quick fix for their pain • Experience a disconnect between mind, body and spirit • To believe “I am my pain . . . it defines who I am.”

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Please note that Prolonged Pain Complex (PPC) is a disorder of body, mind, and spirit. All of the symptoms listed in each category must be addressed and then treated in the order of priority that presents in each individual. We must approach this complex with an integrated team of practitioners who can listen to and evaluate the whole person.

It is not in the scope of this article to detail very aspect of a body mind spirit model, rather to present highlights that will help the readers be more curious and open to the actual process of healing that is available.

It is vital to understand that soft tissue impairment is one of the leading contributors to PPC and it does not show up on magnetic resonance imaging (MRI) or X-ray. It must be evaluated through observation of the client's movement patterns and hands on palpation of the soft tissue, strength, and flexibility testing. Daily life practices and body mechanics must be analyzed.

An individual can experience physical pain for a variety of reasons such as injury, surgery, or trauma. That initial injury will always lead to a reaction in the human soft tissue system as it recoils to protect the individual from pain. Short lived, recoiling is a highly effective self-protective occurrence. When that recoiling turns to prolonged soft tissue restriction/shortening, the chronic problem arises.

As the soft tissue restriction progresses, the individual will develop fascial shortening, adaptive movement patterns, and muscle imbalance. This constellation of symptoms leads to a fear to move at all. With the addition of intense pain medications, these individuals become sedentary and eventually hopeless.

We understand that healing form PPC is a process of change as depicted in the diagram below. This change is a slow process and must be negotiated by helping our clients take tiny/baby steps in learning to live life differently. In our very first two-hour session with a client we are able to quiet the nervous system and reduce their pain significantly. At this point hope is born, trust is established, and the healing begins.

It is critical to understand that the process of change must be supported within a specific relational model. We call that model Ally Support. This specific relational model supports and encourages individuals to learn about themselves. This way they can grow as individuals and heal from the devastation of PPC. From the very first phone call we become our clients ally!!

Allies possess certain relationship/communication qualities: • They can accept us for who we are: validation.

• They truly want us to succeed.

• In their presence we always feel good about ourselves.

• They are not shaming or judgmental.

• They guide rather than lecture.

• They model rather than preach.

• They listen without fixing.

• They give advice only when asked.

• They are consistent.

• They are supportive rather than “shoulding.”

• They communicate clearly and without an agenda.

• They invite interaction with us.

This support model is the real medicine that changes our client’s brain chemistry and floods their systems with the natural hormones of well-being, Lastly, we know that the most effective tool for healing from PPC is self-care. We look at self-care as the daily practices that create the physiologic environment for cellular restoration to occur and the entities of body mind and spirit to re-integrate.

Then and only then will an individual be able to break free from hold of PPC and move out to build a joyful and satisfying life!

Will you join me in changing the face of pain management?

Terrie Carpenter is the founder of Allies for Change, a collaborative health-care practice that specializes Pain Management and Sustainable Recovery. Ms. Carpenter has combined her education, clinical experience, and personal growth process and created The Change Model©, a foundational piece of the philosophy and practice at Allies for Change. She is also an author and speaker.

Michael Genovese is the Chief Medical Advisor of Acadia Healthcare's Recovery Division. He is the former Chief Medical Officer of Sierra Tucson, a world leader in integrative health and part of the Recovery Division. He is principal of Genovese Medical and provides psychiatric Consultation at North Bay Recovery Center in San Rafael, California.He is Assistant Clinical Professor of Medicine at the University of Arizona, a Diplomate of the American Board of Psychiatry and Neurology, and a member of the American Psychiatric Association and of the American Academy of Addiction Psychiatry.

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Medical Education

SAFETY FIRST Drug Education in the Modern World Marsha Rosenbaum, PhD To start my career in this field, I received a doctorate from UCSF, and did research for the National Institute on Drug Abuse. I studied heroin addiction and treatment, crack cocaine, MDMA, and drug use during pregnancy. What seemed obvious to those of us

working in the field was that one of the biggest problems for people addicted to illegal drugs was the criminal justice system.

People addicted to other substances, like alcohol, didn’t go to jail just for possessing or consuming it.

What our study subjects needed was drug treatment to really help them, but they were being arrested instead.

I am also a mother, and I was raising my own children at the time that the war on drugs escalated. Parents were really jumping on the Nancy Reagan “Just Say No” and DARE bandwagon.

The message was all about abstinence, enforced by fear, misinformation, scare tactics, and admonitions like “all drugs are evil and dangerous and no one should ever use them.”

Of course, there definitely ARE serious dangers with using certain drugs, especially methamphetamine and heroin. But I knew that if we lumped all drugs together, it was doing kids a disservice. Kids know they’re not all the same, and they’ll disregard the whole message as a result -they’ll throw the baby out with the bathwater, so to speak. I interviewed heroin addicts who had been told in school that marijuana was addictive.

When they found out it wasn’t, they didn’t believe heroin was addictive, either, so they tried it.

I got involved with drug policy reform for this reason— I wanted to help kids, and not just my own. So I found out as much as I could about drug education, and my career shifted to policy. I went to work for Drug Policy Alliance, opening their San Francisco office. At DPA, I wrote a series of booklets designed for parents of teenagers, to help them navigate the teenage years vis-a-vis drugs. I knew that scare tactics weren’t working—marijuana use was prevalent among teens raised in the DARE and Just Say No era.

Safety First

My “Safety First” booklet is now in its sixth edition, and the advice remains essentially the same. I try to communicate to parents that while abstinence from drugs is the ideal choice, the reality is that kids are confronted with drugs when they enter middle and high school, it’s all around them, and you need a fallback strategy if they do decide to experiment. I tell parents that they need to keep the lines of communication open, to help their kids stay safe.

In school, kids need reliable curriculum based on real, credible, evidence-based information about drugs so they can make informed decisions. We need to equip them to make their own 28

decisions, so that if they experiment with drugs, they know how to reduce the potential harms associated with any drug. They need to learn moderation, self- regulation, and other life skills.

Kids are curious, but they’re also smart. They don’t want to hurt themselves. They often take risks, and parents need to be prepared to work with them. Kids need something to do, and in middle school, they still need supervision. Parents need to spend time with their kids at this age, even though it’s hard for everyone. But supervision and activities outside of school may help keep kids from having the time or inclination to use marijuana. We need resources to keep kids off the streets and engaged. If you keep kids busy, occupied, and passionate, you will also keep them off drugs.

I think we need to look seriously at implementing Student Assistance Programs in high schools—a one-stop shop for drug education, prevention, and treatment. These programs provide counseling, referrals, group therapy and peer to peer accountability. They are a much better alternative to draconian zero tolerance policies, and they help to make safety the number one priority.

Some states have now legalized marijuana. In revising my latest Safety First booklet, I looked at states with commercial, medical, and decriminalized marijuana markets. The prevalence lines in those states are pretty flat in terms of teenage use—it hasn’t gone up, or down. No one really knows why, but that’s because surveys don’t ask the kids their motivation for using or not using drugs—just whether they did or didn’t.

For teens, whether a substance is illegal for adults or not is not the key issue. Marijuana use by children is illegal in ALL states. The key issue with kids is availability—can they get it?

With legal products, the black market is not as large. You don’t see people selling alcohol on the streets, for instance, but that’s exactly where teens get their drugs. Legalization has a chance to put the street dealers—who don’t ask for an ID card—out of business and reduce availability for kids. This regulated, tightly controlled system can hinder teenage drug use.

Talking with Teens

In talking to adolescents, my advice about marijuana is always the same as for alcohol and other substances: It’s much better in terms of health and development to delay your first use. But let’s say they aren’t waiting; in that case, kids should learn as much as they can about marijuana. Research it on unbiased websites. It’s not true that it’s all good or all bad. It’s not harmless, but it’s not proven to cause permanent harm to your IQ if you smoke it once. I tell parents to work with kids themselves - teach them to be skeptical and practical. You want to encourage them to reduce the harms—and if they’re going to do it,

SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

just limit it to once in a while. Don’t do it all the time, don’t drive while intoxicated, and understand that intoxication can impair decision making abilities.

Remember, we’ve always had laws on the books to protect kids from getting ahold of intoxicants. Methadone has to be kept in a locked box in the home. We also know that criminalization of drug use, especially for youth, is bad for everybody.

We don’t want kids caught up in the criminal justice system.

Let’s craft legislation that is as protective as it can possibly be, and shifts the way we deal with marijuana in this state. That’s the most rational and safe choice we can make for our kids.

Marsha Rosenbaum is Director Emerita of the Drug Policy Alliance, San Francisco. She has authored numerous articles, books, and reports about drug use, misuse, and treatment, including “Safety First: A Reality Based Approach to Teens and Drugs,” and “Making Sense of Student Drug Testing: Why Educators are Saying ‘No’.” She is a nationally recognized expert on teens and drug use.

For more, see, https://www.drugpolicy.org/docUploads/safetyfirst.pdf

T H E C A L I F O R N I A M E D I C A L A S S O C I AT I O N A N D T H E C A L I F O R N I A M E D I C A L A S S O C I AT I O N F O U N D AT I O N P R E S E N T T H E 2 1 ST A N N U A L

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HEALTH POLICY PERSPECTIVE SAFER DRUG CONSUMPTION SERVICES SFMMS Supports Supervised Injection Centers Pilot Safer drug consumption services (SCS) are health care settings where people can more safely use preobtained drugs in a hygienic environment with access to sterile drug use equipment and under the supervision of trained healthcare staff. SCS provide healthcare, counseling, and linkage to other services, including drug treatment. They promote dignity and connection for people too often denied both.

There are more than one hundred SCS programs operating in ten countries (Australia, Canada, Denmark, France, Germany, Luxembourg, the Netherlands, Norway, Spain, and Switzerland)—but none in the United States. More SCS are planned to soon open in Ireland and in many Canadian cities. In the United States, the Seattle and King County, Washington governments have stated an intention to authorize SCS; state-level legislation has been introduced in California, Maryland, Massachusetts, and Vermont; and the city legislatures of San Francisco and New York City have taken steps to explore the viability of local SCS authorization.

Scores of high-quality, peer-reviewed scientific studies have consistently proven the positive effects of SCS on public health and safety. Public health research has shown that SCS: • Reduce overdose deaths by providing immediate first aid.

No one has ever died while using drugs in an SCS. • Increase access to drug treatment, especially among people who distrust the treatment system and are unlikely to seek treatment on their own.

• Increase public order and safety by reducing drug use in public spaces such as parks and public restrooms, and reducing improperly discarded drug use equipment.

• Reduce HIV and viral hepatitis transmission by eliminating the sharing of drug use equipment by people who use at an SCS. • Reduce skin and soft tissue infections, a common, debilitating, and expensive-to-treat consequence of injection drug use in unsanitary environments.

• Save money by preventing disease and unnecessary hospitalization. A recent San Francisco cost-effectiveness study predicted that a single SCS would result in a net annual savings of $3.5 million for the city.

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In addition, research has shown that SCS do NOT: • Increase drug use in the surrounding community.

• Increase initiation into injection drug use.

• Increase drug-related crime.

• Attract new drug users to an area.

California's longstanding commitment to harm reduction services has been a model for cities around the world, and has resulted in sharp reductions in HIV transmission and overdose deaths among people who inject drugs. But changing drug use issues, including the widespread introduction of fentanyl, and ongoing challenges with homelessness speak to the need for a holistic, evidence-based approach to reducing the harms of drug use.

SCS will save lives in California. Without them a vital tool is left unused, resulting in more disease and death among our families and loved ones. For the health and safety of our state, we call on California to act now.

" Editor: Supervised Injections Centers may represent a concept that strikes some people as counterproductive. However, the same was said years ago about syringe exchange efforts, which have been shown to not only prevent transmission of harmful diseases but also facilitate the entry of some drug users into treatment programs.

Thus, after examining the evidence, the San Francisco Marin Medical Society board of directors, composed of physicians from many specialties throughout our two counties, has voted to endorse the concept and a trial of such efforts here. We feel that this too could work to both decrease the incidence of infectious diseases and help drug users access needed drug treatment. The opioid abuse epidemic is indeed a crisis, which requires every possible means of lessening it."

—Man-Kit Leung, MD President (From a letter to the San Francisco Chronicle) Much more data and information available at: https://www.yestoscscalifornia.org/facts/

SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

SFDPH UPDATE SFDPH Update—Mumps and Pertussis: Vaccine-Preventable But Still a Concern

Dr. Eric Tang Both mumps and pertussis are vaccine-preventable diseases that nonetheless occur with frequency in the United States. Despite relatively high uptake of routine vaccina-

tion during childhood, there have been increases in mumps and pertussis cases and outbreaks in recent years. These increases may be in part due to waning immunity in immunized individuals.

Healthcare providers should be knowledgeable about these diseases given the recent increases in activity.

Mumps is caused by a single-stranded ribonucleic acid (RNA) virus in the paramyxovirus family. It is spread by infectious respiratory droplets and has an incubation period of twelve to twentyfive days. The Centers for Disease Control (CDC) recommends a two-dose series of the live-attenuated Measles, Mumps & Rubella (MMR) vaccine for children at twelve through fifteen months of age with the second dose given at age four to six years before entering kindergarten or first grade. One and two doses of the vaccine are estimated to be approximately seventy-eight and eighty-eight percent effective, respectively.

Asymptomatic mumps infections are common; however, the most frequent clinical manifestation of mumps is unilateral or bilateral parotitis, which occurs in thirty-one to sixty-five percent of patients. Non-specific prodromal symptoms include myalgias, loss of appetite, malaise, headache, and low-grade fever. Orchitis and oophoritis are relatively specific findings of mumps and thus should prompt workup for the disease. Rarely, mumps can lead to meningitis, encephalitis, pancreatitis, or deafness.

Patients who are suspected of having mumps should be tested with a buccal swab specimen for mumps virus by reverse transcriptase polymerase chain reaction (RT-PCR). It is recommended to obtain testing through a public health laboratory. (San Francisco providers should contact the San Francisco Department of Public Health Communicable Disease Control Unit at 415-554-2830, while Marin County providers should contact the Marin Health and Human Services Communicable Disease and Prevention Control Unit at 415-473-4163). Serum mumps IgM tests can also be helpful for diagnosis, but careful interpretation is needed as false negatives may occur, particularly in vaccinated individuals. Mumps is most infectious several days before and after the onset of parotitis; therefore, patients suspected of mumps should be isolated at home for five days after the onset of parotitis. There is no effective postexposure prophylaxis for mumps.

Pertussis, also known as whooping cough, is a highly contagious disease caused by the aerobic gram-negative rod bacterium Bordetella pertussis. Pertussis immunization involves a four-dose primary series of DTaP vaccine beginning in infancy, with a fifth dose given before starting kindergarten, and an additional booster dose at age eleven to twelve years. Adults aged ≥ nineteen years should receive a single dose of Tdap. Given that infants are at highest risk of hospitalization and death from pertussis, pregnant women WWW.SFMMS.ORG

should receive Tdap during each pregnancy, in weeks twenty-seven to thirty-six, in order to maximize the maternal antibody response and passive transfer of antibodies to the newborn.

Since widespread implementation of the pertussis vaccine in the 1940s, reported cases have dramatically decreased; however, there has been an increase in activity of pertussis in recent years in the United States and California, with peak incidence every three to five years. Outbreaks among adolescents in settings such as schools and camps are common. The use of acellular pertussis vaccine (which was substituted for whole-cell vaccine in the 1990s) may provoke a less durable immune response. California had an epidemic of pertussis in 2014, which involved 456 hospitalizations and three deaths. Since 2014, cases have declined, but given the cyclical nature of pertussis, another outbreak is likely to occur in the next several years.

The incubation period of pertussis is typically between seven to ten days. The first (catarrhal) stage of the infection includes runny nose, sneezing, low-grade fever, and mild cough. The second (paroxysmal) stage involves cough paroxysms that end with a long inspiratory effort often associated with a high-pitched “whoop.”

During attacks, patients can become cyanotic. Infants <six months old have paroxysms of coughing but may not demonstrate the characteristic whoop due to decreased strength; they may have apneic spells. Immunized individuals may be asymptomatic or have milder disease, and the characteristic inspiratory whoop is usually not present.

Young infants are the most likely to suffer complications related to pertussis. Secondary bacterial pneumonia is the cause of most pertussis-related deaths, which occur largely in young infants.

Additional complications include seizures and encephalopathy.

Clinical criteria for diagnosis of pertussis include cough for >two weeks with whoop, paroxysms, and/or posttussive vomiting. While culture is considered the gold standard for laboratory testing, B. pertussis is a fastidious organism that is challenging to culture. Polymerase chain reaction (PCR) from posterior nasopharyngeal specimens has high sensitivity if obtained within three to four weeks of cough onset. Serologic testing is not recommended for the workup of pertussis.

Treatment for pertussis is mainly supportive, but antibiotics can decrease transmission and potentially modify the course of illness if started early. A macrolide, such as azithromycin, is the preferred treatment. Secondary attack rates are eighty percent among susceptible household contacts, and thus all close contacts should receive antibiotic postexposure prophylaxis regardless of age or immunization status. Prioritization should be given to “high-risk” close contacts such as infants and pregnant women.

A full list of references can be found at www.sfmms.org.

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MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

Kaiser Permanente Maria Ansari, MD

At California Pacific Medical Center, we are committed to improving patient safety and quality. In hospitals across the United States, medical errors remain a major contributor to adverse patient outcomes. We have implemented the Patient Safety Alert System (PSAS) to maintain a consistent, systematic approach to investigating events that may have or could have resulted in serious consequences. We refer to these events as “Red Events.” This process has allowed our multidisciplinary team to understand the root causes of Red Events.

The PSAS ensures that timely, efficient, and coordinated actions are taken in response to the event in order to prevent recurrence. The team analyzes both the systems and processes of care to identify the root causes and secondary causes of harm. Next, a critical focus is placed on redesign or development of new systems to ensure safer processes for patient care. The team aims to make it impossible for the same mistake to happen twice. The development of an action plan is always coupled with a measurement strategy to ensure that the new processes developed stay in place and are effective.

Since we launched the PSAS, we have averaged approximately one Red Event every two weeks, but we have noticed increasingly longer periods between events. One way that we have driven this culture change has been through distribution of a publicly shared “Red Event Memo” from our Chief Executive Officer, Dr. Warren Browner. After each event, the memo is sent to all staff regardless of position at the medical center. The memo specifically outlines what happened, the corrective actions implemented, and what we all can learn from the event. We believe that our PSAS is emblematic of our commitment to transparency in patient safety, quality, and the delivery of highly reliable care to all of our patients.

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It seems we cannot pick up a newspaper nowadays without headlines blaring: Opioid addiction declared epidemic! Ironically, the most commonly abused drugs—alcohol and tobacco—don’t make headlines.

Still, at Kaiser Permanente—with our decades-long emphasis on prevention—we have always been proactive in addressing drug problems. We have successfully implemented universal screening and treatment for at-risk alcohol and tobacco use throughout primary care.

Now, we are mobilizing our whole delivery system to get in front of the opioid epidemic—to reduce the impact of opioid misuse in our member population.

As physicians, we cannot ignore our role in seeding the opioid epidemic ravaging our country’s young people, some dying of overdose. The late twentieth century mantra to extinguish all pain through the liberal use of opiates created an opioid epidemic fueled by the rampant availability of drugs like vicodin, oxycontin, and percocet. It’s taken years for the medical community, led by our colleagues at the Centers for Disease Control (CDC), to understand the scope of this catastrophe. We are grateful for the CDC’s recognition of the opioid epidemic and its new guidelines to help physicians better manage pain.

By leveraging our integrated system and partnership with pharmacists, our physicians at Kaiser Permanente are implementing the CDC recommendations calling for regular visits, urine drug screens, and opiate contracts.

Standing frontline with our physicians, pharmacists explain the risks and benefits of longterm chronic opiate therapy, provide patient centered opiate tapers, and help physicians implement step-wise care with high fidelity.

Opioid abuse may be widespread, but with the use of the CDC guidelines and leveraging our integrated system, we can address both the immediate and ongoing issues associated with the epidemic.

SFMH

Robert Harvey, MD, MBA, CPE

This month, San Francisco will host attendees of the Minimally Invasive Surgery Week conference. Mona Orady, MD, medical director of Robotic Surgery and gynecologic surgeon at Dignity Health Saint Francis Memorial Hospital, helped organize and will present during the conference, which is put on by the Society of Laparoendoscopic Surgeons.

During her talks, Dr. Orady will touch on advancements in minimally invasive surgery including da Vinci robotic surgery for complex cases as well as mini/microlaparoscopy—a virtually painless, almost scarless surgical option offered by Saint Francis for treating several gynecologic issues. These minimally invasive techniques are typically performed as a same-day procedure under general anesthesia with the da Vinci robot, resulting in less pain and a quicker recovery for most women.

Dr. Orady is dedicated to advancing the field of minimally invasive surgical techniques so that patients can return to their daily activities more quickly. It is too costly for the patient and for society to require days in the hospital and weeks off work after gynecological surgery, she says. Because of this, many patients will suffer in pain for months or even years by putting off necessary procedures due to family or work commitments.

Surgical techniques and devices have evolved and enhanced to the point where most open surgeries can be replicated using minimal access techniques. And in many cases, if open surgery or laparoscopic gynecologic surgery is needed, robotic assisted surgery or mini/microlaparoscopy can be used instead.

Robotic surgery can often give patients with complex pathology such as severe endometriosis, large fibroids, or large ovarian cysts an alternative to open laparotomy. Mini/microlaparoscopy can be used to diagnose, biopsy, and treat causes of pelvic pain including endometriosis, fibroids, and several other conditions.

SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

SMMC

Carl Bricca, DO

Dignity Health St. Mary’s Medical Center recently received several commendations, including recognition for our stroke, cancer, and diabetes programs.

St. Mary’s stroke program earned The Joint Commission’s Gold Seal of Approval® and the American Heart Association/American Stroke Association’s Heart-Check mark for Advanced Certification for Primary Stroke Centers. The Gold Seal of Approval® and the Heart-Check mark represent symbols of quality from their respective organizations.

Our stroke program also recently earned the American Heart Association/American Stroke Association’s Get With The Guidelines® - Stroke Gold Plus Quality Achievement Award and also qualified for recognition on the Target: Stroke Elite Honor Roll.

The award recognizes our commitment to providing the most appropriate diagnosis and treatment of stroke according to nationally recognized, evidence-based guidelines.

The Commission on Cancer of the American College of Surgeons has again granted a Three-Year Accreditation to the St. Mary’s cancer program. Led by Robert Weber, MD, medical director of Oncology Services, St. Mary’s takes a multidisciplinary approach to treating cancer as a complex group of diseases that requires consultation among surgeons, medical and radiation oncologists, diagnostic radiologists, pathologists, and other cancer specialists. The St. Mary’s Diabetes Self-Management Education program has again been designated an American Diabetes Association-Recognized Education Program. Programs that achieve this recognition are supported by a staff of knowledgeable health professionals who can provide state-of-the-art information about diabetes self-management for patients with diabetes and pre-diabetes, as well as their families. I would like to thank our dedicated clinicians, caregivers, and staff who continuously strive for excellence by providing exemplary patient care, and help St. Mary’s achieve more accomplishments each year.

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CLASSIFIEDS:

ZSFG

Malini K Singh, MD,MPH

The new Zuckerberg San Francisco General Hospital (ZSFG) opened its doors in May 2016.

The Emergency Department started its preparation for this move a few years in advance, with our first introduction to Lean Methodology (LEAN) in 2014. We started with a series of planning (3P), organizing (5S), and improvement (Kaizen) workshops. Our interdisciplinary team gathered data through direct staff observations and created a value stream map of our "current state.” We then used this data to create a "future state" and perform a gap analysis to identify opportunities for improvement. Through the implementation of LEAN/A3 thinking we created PDSA (plan-dostudy-act) cycles to drive rapid improvement testing of identified areas. One key opportunity was implementation of a Fast Track.

Through our analysis, we learned that a significant percentage of our patients were low acuity (Emergency Severity Index 4/5), possibly due to lack of access to primary care and/or urgent care appointments. As a level one trauma center, these patients were consistently deprioritized, with long lengths of stay. We started our Fast Track in December 2015 while we were still housed in our old Emergency Department (ED). Over just a few short months, we saw a decrease in the average length of stay of discharged low acuity patients of almost thirty percent. After our move into our new ED, our length of stay for these patients increased by thirty percent. Fortunately, because of our ongoing LEAN work—which includes daily huddles and review of data—we were able to rapidly identify and address the issue. The length of stay has improved by fifteen percent and continues to decrease. Overall, with the implementation of our Fast Track, we have seen improved flow metrics for discharged low acuity patients, reductions in our “left without being seen” rates, improved staff engagement, and the ability to care for increased numbers of patients. The process has illustrated to our entire Emergency Department team at ZSFG the value of standard work and data-driven improvement. We look forward to our ongoing journey with LEAN to help us learn and improve upon our processes to deliver more timely, efficient, and patient-centered care.

Medical and dental space 2,000 sf and up in newly upgraded Pacific Vision Foundation building at 711 Van Ness Ave, SF. Ford Griswold, Bayside Realty Partners, 415-990-7004 or fgriswold@baysiderp.com.

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UPCOMING EVENTS VitalTalk: Mastering Tough Conversations October 4, 2017 | Preservation Park, Oakland, CA This interactive course is the first in a series of courses VitalTalk is bringing to the Bay Area. It is designed for providers including physicians, advanced practice nurses, and physician assistants.

Get the tools you need to lead honest discussions with seriously ill patients and their families about prognosis and goals of care.

Providers from a range of practice settings and specialties are encouraged to attend. Learn more at www.vitaltalk.org/courses.

NEPO Building Healthy Communities Summit

October 19-20, 2017 | Disneyland Hotel, Anaheim, CA The 2017 Network of Ethnic Physician Organizations (NEPO) Building Healthy Communities Summit will be held on October 19-20 at the Disneyland Hotel in Anaheim. The theme this year is "Striving for Health Equity in the Era of Change." Register today at bit.ly/2tTSFXb.

CMA House of Delegates Meeting

October 21-22, 2017 | Disneyland Hotel, Anaheim, CA The House of Delegates convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health, and CMA governance issues. Policies adopted by the House are implemented by the Board of Trustees, which also deals with the many interim policy issues that arise between annual sessions. Learn more at bit.ly/2uipWOG.

ber physicians. More information and registration will be available soon at https://www.sfmms.org/events.aspx.

UPCOMING WEBINARS

Assembly Bill 72: How to Challenge the Interim Payment for Out-of-Network Services at In-Network Facilities September 27, 2017, 12:15-1:15pm Last September, Governor Jerry Brown signed a controversial bill, Assembly Bill 72, into law. This law, implemented July 1, 2017, changes the billing practices of non-participating physicians providing non-emergent care at in-network facilities including hospitals, ambulatory surgery centers, and laboratories.

The new law requires plans and insurers to reimburse physicians at an interim rate. However, it also includes mechanisms for physicians to challenge the interim payment. Join CMA to learn about the different options for challenging the interim payment, including the newly created Independent Dispute Resolution Processes with both regulators, an overview of how to access the dispute options, and California Medical Association (CMA) resources available to assist physician members. Click here to register: http://bit.ly/2vJOUqq.

Mastering the Art of Disclosing an Unexpected Outcome

November 7 & November 14, 2017 When an unexpected outcome occurs, a discussion explaining what happened can help prevent a negative patient response and can actually improve patient trust and reduce the risk of a lawsuit, yet few physicians have been trained in this specialized set of communication skills in how to effectively manage these difficult conversations. With this in mind, MIEC has created an interactive workshop that examines the elements of providing a timely and effective disclosure when an unexpected outcome occurs. This three-hour evening workshop is free to SFMMS mem-

SAVE THE DATE: SFMMS 150th Anniversary Celebration & Gala

March 15, 2018 | St. Francis Yacht Club, San Francisco, CA In 2018, SFMMS will celebrate its 150th Anniversary. Save the date for a celebration not to be missed! More information and registration will be available soon at https://www.sfmms.org/events.aspx. Sponsorship opportunities availableâ&#x20AC;&#x201D;contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

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SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2017 WWW.SFMMS.ORG

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REASONS TO JOIN CMA AND YOUR COUNTY MEDICAL SOCIETY

TOGETHER WE ARE STRONGER

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California Medial Association (CMA) and its county

Through aggressive political and regulatory

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advocacy, CMA and its county medical societies

physicians for 160 years as the recognized voice

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SHAPE THE FUTURE OF MEDICINE Members receive direct access to our state and

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From tobacco use and obesity to prescription drug

PROTECT THE PROFESSION Your membership affirms your commitment to the medical profession and ensures physicians remain in control of the practice of medicine.

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abuse and vaccinations, your membership dollars support forward-thinking public health advocacy to improve the health of Californians.

PROTECT MICRA CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after

Members receive one-on-one assistance from CMA’s

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01.23.2017