WCPM July 2013 by Tina Frost

Celebrating medicine, the arts, intellect, ideas and curiosity.

contents 10

suboxone: to prescribe, or not to prescribe it

6 welcome new WCMS members 8 ajax and madness in the tragic hero 17 serving as a physician volunteer 18 pharmacogenomics and its utility in medication dosing 20 brief on 2012 american academy of neurology migraine prevention guide lines

22 update on 2013 ADA diabetes standards of care

28 project access 2012 thank youâ&#x20AC;&#x2122;s

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contributors

WCPM July 2013 Publisher Wake County Medical Society Editor Paul Harrison Wake County Medical Society Officers and Executive Council

Council Terry Brenneman, MD Members David Cook, MD Kimberly Durland, MD Warner L. Hall, MD Ken Holt, MD M. Dixon McKay, MD Assad Meymandi, MD, PhD, DLFAPA Robert Munt, MD Dale Oller, MD Patricia Pearce, MD Barbara Savage, MD Derek Schroder, MD Michael Thomas, MD Annette Troy, MD Brad Wasserman, MD Susan T. Weaver, MD Andrew Wu, MD WCMS Deb Meehan Alliance Louise Wilson Co-Presidents

Wake County Physician Magazine (WCPM) is a quarterly publication for and by the members of the Wake County Medical Society. Wake County Medical Society 2500 Blue Ridge Road, Suite 330 Raleigh, NC 27607 Phone: 919.782.3859 www.wakedocs.org “The Wake County Physician Magazine is an instrument of the Wake County Medical Society; however, the views expressed are not necessarily the opinion of the Editorial Board or the Society.”

L. Jarrett Barnhill, MD is a professor of Psychiatry at the UNC School of Medicine and the director of the Developmental Neuropharmacology Clinic within the Department of Psychiatry. He is a Distinguished Fellow in the American Psychiatric Association and Fellow in the American Academy of Child and Adolescent Psychiatry. John O’Dell is a Registered Nurse and started with the CATCH Program at CCWJC in January 2013. He graduated from Wake Technical Community College in 2005 and received his Master’s Degree in Nursing in 2010. He also holds an MBA. Currently, he is working as a community-based transition care coach.

Patricia Pierce, MD is a psychiatric physician in private practice in Raleigh for over 20 years, prescribing Suboxone for approximately 5 years.

Dixon McKay, MD has practiced gastroenterology for 25 years. He has provided service through many volunteer roles, including the current president of the Wake County Medical Society.

Wake County Physician Magazine is published quarterly by the Wake County Medical Society. Please direct comments or requests to: Tina Frost, Graphic Editor tina@tinafrost.com 919.671.3963

contributors Lisa Rowe joined the CapitalCare Collaborative as Project Manager for the Wake Crisis Cooperative in January 2009. A year later she stepped into the role of CCC Director. Prior to coming to the CCC, she spent five years managing National Service Programs in the southeast and gulf coast regions with Habitat for Humanity International. Lisa has a BA in Psychology and a Master’s degree in Public Administration from NCSU. Her career has been spent working in the public and non-profit arenas developing and managing programs for various at-risk populations including the homeless, ex-offenders, immigrant families, and youth. She has also overseen an energy assistance program and been involved in developing programs for affordable housing residents. Rachel Smith is a 4th year pharmacy intern from the UNC Eschelman School of Pharmacy. She recently completed a 2013 rotation with the Community Care Program of Wake and Johnston Counties under the supervision of Cheryl A. Viracola, PharmD, Pharmacy Programs Coordinator for CCWJC. The preceding article on Migraine treatment is part of a research project assigned during her clerkship.

Courtney Bradley is a 4th year pharmacy intern from the UNC Eschelman School of Pharmacy. She recently completed a 2013 rotation with the Community Care Program of Wake and Johnston Counties under the supervision of Cheryl A. Viracola, PharmD, Pharmacy Programs Coordinator for CCWJC. The preceding article on diabetes is part of a research project assigned during her clerkship.

Todd McKeon is a 4th year pharmacy intern from the UNC Eschelman School of Pharmacy. He recently completed a 2013 rotation with the Community Care Program of Wake and Johnston Counties under the supervision of Cheryl A. Viracola, PharmD, Pharmacy Programs Coordinator for CCWJC. The preceding article on Pharmacogenomics is part of a research project assigned during his clerkship.

A special thanks to our WCPM July 2013 Advertisers

Wake County Physician Magazine (WCPM) is a publication for and by the members of the Wake County Medical Society. WCPM is a quarterly publication - published January, July, April, and October. All submissions including ads, bio’s and photo’s for the WCPM should be directed to: Tina Frost, Graphic Editor tina@tinafrost.com 919.671.3963 Photographs or illustration requirements: submit as high resolution 5” x 7” or 8” x 10” glossy prints or a digital JPEG or TIF file at least 300 DPI no larger than 2” x 3” unless the artwork is for the cover. Please include names of individuals or subject matter for each image submitted. Contributing author bio’s and photo requirements: Submit a recent 3” x 5” or 5” x 7” black and white or color photo (snapshots are suitable) along with your submission for publication or a digital JPEG or TIF file at least 300 DPI no larger than 2” x 3” (If submiting by US Mail please contact Tina for mailing address.) All photos will be returned to the author. Include a brief bio along with your practice name, specialty, special honors or positions on boards, etc. Please limit the length of your bio to 3 or 4 lines. Advertising Rates and Specifications: Full Page $800 | 1/2 Page $400 | 1/4 Page $200 Camera ready artwork may be submitted in PDF JPEG or TIF format.

wcms president’s letter Why Join WCMS? What’s the point? Because change is in the air and because the knotty problems associated with medicine are always changing. It was the birth of the new millennium when health in the United States switched from fighting disease to managing behavioral causes that were causing disease. When we took the Hippocratic Oath we made a pledge and joined a family.

emember just 12 years ago when the Mac computer was dying and then a little iPod began the thrust to propel Apple into the mainstream and ever sense we’ve seen many remarkable changes to the music industry, computers, cell phones and we have even eliminated the home phone at our house. That was a dramatic change. We are now in the midst of experiencing such an earthquake of change in healthcare. Change does produce excitement but it definitely is disconcerting and uncomfortable as we undergo the transitions. We as physicians, know the way of the CD player. It has been a while since I even thought about a cassette or 8 Track. I still have my record collection but no longer the player. And so, as we are propelled into the future of changes in healthcare, the unchartered waters may or may not be treacherous but how do we anticipate the medical version of the cassette and how do we prepare for the unknown?, Theologian, Anthony de Mello stated, “people want a cure provided they can have it without pain are like those who favor progress, provided they can have it without change.” When it comes to healthcare, there is no better advocate than the physician. Together, we are able to navigate the changes. The Wake County Medical Society provides a supportive community for the physician, an avenue for participation, discussion and support as the changes take place. It also creates time for us to develop lifelong friendships. In a community growing at the speed of Wake County, one of the fastest growing communities in the country, according to Forbes Magazine, one can easily feel as though each of us is not an integral part. The speed of life and divisions pulls at us. And with healthcare decisions being made in Washington, one can feel their ability to contribute to outcomes dwindle. The diversity of the Medical Society being comprised of specialist and primary care physicians alike, may seem to dilute the reasons for joining. We are like all families, not without our differences. But we are better together, learning from each other than alone. The common thread that binds us is so much stronger than the winds of change and the dissection of the whole. The Art of practicing medicine is a sacred profession. Those in the trenches use their exper-

tise, skill, curiosity, knowledge and wisdom to assist patients with decisions large and small and optimal treatments. We strive mightily to provide a foundation for the best health possible, knowing that ones health is their most important asset. Physicians are honored to walk with patients in times of joy and agony. We cherish being with people at the 1st moments of life and morn the last breaths. It is an honor and a privilege. It is a unique family. The Wake County Medical Society has successfully carried the banner and dealt with issues concerning healthcare, patients and providers since 1903. It is an important part of the community and we can take pride in the our part of creating a community that is thriving. A distinguished past filled with outstanding contributions of remarkable physicians created the environment that attracted me and many of you to Wake County. I enjoy working beside the dedicated physicians that presently navigate patients to receive the finest healthcare in the country and we look forward to an indispensable future. I know my colleagues, rich in diversity in every aspect, possessing talents that benefit the whole of our society both medically and with a full array of interests beyond. It is crucial that during this time of change we come together as physicians striving to impact healthcare, to learn from each other, to advocate for prevention, to address the needs of the underserved, to give voice for the wellbeing of all patients. The Wake County Medical Society needs each one of us! If you are already a member, ask a friend to join! In a YouTube 2007 interview with Steve Jobs, Bill Gates quotes Steve, “we build the products we want to use”. Addressing issues and delving into problems is what physicians do best. And remember the immortal words of Sister Sledge, “We are Family.”

M. Dick McKay, M.D.

“As physicians, we have so many unknowns coming our way... One thing I am certain about is my malpractice protection.” Medicine is feeling the eﬀects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to an atmosphere of uncertainty and lack of control. What we do control as physicians: our choice of a liability partner. I selected ProAssurance because they stand behind my good medicine and understand my business decisions. In spite of the maelstrom of change, I am protected, respected, and heard. I believe in fair treatment—and I get it.

Professional Liability Insurance & Risk Management Services ProAssurance Group is rated A+ (Superior) by A.M. Best. ProAssurance.com å 800.292.1036

The Wake County Medical Society, with over 700 physician members, has been a trusted source of health policy leadership since 1903 when it was chartered by the North Carolina Medical Socity. Additionaly, the not-for-proit arm of the WCMS, the Community Health Foundation, is recognized for it’s long and effective history of providing service to underserved patient populations.

John M. Erickson, MD Medical School: University of Texas Southwestern Medical Center at Dallas Year Graduated: 2004 Speciality: Orthopedic - Surgery of the Hand Practice: Raleigh Hand Center

Speciality: Urgent Care

Kimberly W. McDonald, MD Medical School: Eastern Virginia Medical School Year Graduated: 1985 Speciality: Public Health

Claudia Y. DiGiaimo-Nunez, MD

Nevin M. Shrimanker, MD

Medical School: University of South Florida College of MedicineSouthwestern Medical Center at Dallas Year Graduated: 1998 Speciality: Psychiatry Practice: Carolina Partners in Mental Health

Medical School: Wake Forest University School of Medicine Year Graduated: 2004 Speciality: Anesthesiology Pain Management

Theresa M. Flynn, MD

Scott D. Wagner, MD

Medical School: Duke University School of Medicine Year Graduated: 1996 Speciality: Pediatrics Practice: Wake County Child Health Clinics

Medical School: University of Pittsburgh Year Graduated: 1997 Speciality: Family Medicine Practice: Wakefield Medical Care

Michael Golding, MD

Valerie L. Cumbea, PA-C

Medical School: Ohio State University/Columbus Year Graduated: 1991 Speciality: Psychiatry Practice: Triangle Family Services

Primary Area of Practice: Hospitalist

Melvin G. Lee, MD

Addison J. Korzun, PA-C

Medical School: Dalhousie University Faculty of Medicine Year Graduated: 1980

Primary Area of Practice: Neurological Surgery

Dawn P. Evancho, PA-C Primary Area of Practice: Family Medicine

JOIN TODAY!

Ajax and Madness in the Tragic Hero By L. Jarrett Barnhill, MD

s a playwright Sophocles was an innovator. He disregarded the conventional ×

and antagonist to the genre. Sophoclean heroes were emotionally distant, vulnerable to shame and prone to extreme outpourings of compensatory violence. Their greatest flaw was stubborn inflexibility, manifested by an inability to listen to reason or compromise when it was in their best interest. The antagonist had the unenviable job of trying to avert the hero’s catastrophic and selfdestructive course of action. The most familiar examples of his tragic heroes are found in Oedipus the King, Antigone, and Oedipus at Colonus. These free-standing tragedies traced the story of Oedipus and his children. We will not focus on these familiar tragedies but instead explore one of his earliest plays, Ajax. Ajax presents several twists on the concept of madness. The play opens with Odysseus and his patroness Athena discussing the bizarre behavior of Ajax. Prior to these speeches, Ajax was shamed by his fellow Greeks who awarded the armor of Achilles to Odysseus. Enraged he sought vengeance against them. Were it not for Athena’s magic, Ajax would have murdered his fellow Greeks (including Odysseus Menelaus and Agamemnon). Athena saved them by tricking Ajax into slaughtering sheep and goats instead of his fellow warriors. Once his fury passed, Ajax realized that he was deceived and would be now vulnerable to further ridicule. Oddly, Athena added

trilogy format of his time, and created plays that stood as independent productions. He also introduced the tragic hero [continued on page 13]

Consider the following real-life cases from my current practice: Mr. A. has just accepted a specialized and well-paid job with a cable company, after completing the progressive coursework required in the telecommunications field í

over the last 6 months or so to qualify- his first schooling since he dropped out from HS some years back due to substance problems then. It has also been the occasion for discontinuation of his chronic marijuana usewith the real-time (and firsttime) insight that it was incompatible with success in the technical coursework involved, as well

as feeling and functioning far better when not using it. This follows leaving his third-shift stocking job that he held for several years- which in turn was his first yearslong stretch of stable employment in his young adulthood. Mr. B. is now settled into a local job with

the CDL (commercial driving license) that he earned a year ago, after literally broadening his horizons from his North Carolina roots that he had never left before with cross-country driving. It is his first stable, living wage daytime job for this high school graduate, with earlier employment limited to swing shift manufacturing work. (He is now in his thirties.) His relationship with a longtime partner has never been more stable, and he has totally separated himself for 2 years now from his former lifestyle characterized by regular weekend cocaine use with friends. Ms. C. a single parent, is recently engaged to the partner who has lived with her for a year and is highly invested in continued co-parenting of her toddler. She has also recently left the waitressing work at which she has supported herself for several years, for a more regular administrative day job which (for her first time) will provide the medical and other benefits she has never had before for herself and her child.

hat do these people all have in common? They are all Suboxone patients- having left their earlier lives in the shadows of opiates abuse that they were entrenched in for years before seeking treatment for their opiate dependency. All three have maintained years of sobriety at this point from opiates (going on 3 years, 2 years, and 2 years respectively) after a yearslong pattern of abuse that preceded treatment

(4 years, 3 years, and 4 years respectively), and the 2 of them that retained regular abuse of other substances early on have now also renounced their use and the lifestyle that went with it. All 3 have been maintained on continued Suboxone (though are on lower dosing than when originally started on it); all will probably need indefinite continuation of it to maintain these lifestyle gains- but are, along with their prescribing physician, open to longterm further tapering that might allow eventual discontinuation of it. Suboxone, a combination of the partial-agonist opiate buprenorphine and the opiate antagonist naloxone, has been an FDA-approved treatment for opiate dependency since the advent of the DATA act (Drug Abuse Treatment Act) in 2000allowing office-based treatment of this condition for the first time. In addition to being more accessible than methadone as a substitution treatment (which requires a federallycertified clinic to administer), it is also a far safer drug than methadone in overdose; even when illegally diverted, it has many times been the motivator to street users to seek their own treatment on it as opposed to continued living in the shadows with a heroin or pill addiction. Federal law allows newly certified prescribers to treat up to 30 patients in their first year; after that, application can be made to treat up to 100 patients by any given practitioner. The usual route to certification is through an 8 hour, daylong course. Some of the associated controversies with Suboxone

include duration of treatment, adequate counseling followup in concert with the use of Suboxone, diversion of it to the street, and the usual trust issues that are always at play in the treatment of substance abuse. Speaking as a psychiatrist and prescriber of Suboxone for 5 years now, I would offer up the following observations on each: • Duration of use: While Suboxone was originally touted as primarily a temporary vehicle to wean people off of street opiates before then being weaned off of Suboxone, the reality in my observation is that if someone has exhibited a physical dependency on opiates for 2 years or more, they will be unable to ever successfully discontinue Suboxone without having the insatiable cravings that nearly always lead to a relapse; this is not inconsistent with a medical model that posits irreversible changes in the neural pathways that are sensitive to opiates depending on severity and duration of abuse that they’ve been subjected to. Physical dependency for 6 months has a much better prognosis, with dependency spanning 6-24 months being a gray zone between the two in my experience. And the mortality from relapse into chronic opiate abuse is staggering, at up to 10% yearly from some studies either from inadvertent overdose or complications of drug use. • Counseling followup: All Suboxone literature supports a better prognosis with counseling supports, and it is a federal stipulation that access to it be provided. That [continued on page 12] ø

suboxone continued being said, thereâ&#x20AC;&#x2122;s a great deal of individual variation among patients as to insight and progress with their own dependency issues, as well as duration of treatment and cumulative years of successful abstinence factoring in to the need for continued longterm counseling support. For some, motivation is sufficient that their needs are minimal beyond a supportive 10 or 20 minute office visit monthly once they are stable on it, or participation in a 12 step group. For others, formal rehab programs may be necessary all the way up to inpatient status. A rule of thumb is that for every relapse, the reinstituted treatment requires proactively ratcheting up the level of care; if someone repeatedly fails office-based care, then they are no longer appropriate for it and should be referred to a formal program. â&#x20AC;˘ Street diversion: Despite any safeguards taken, some of your patients will be diverting some of their Suboxone to the street. (This is not unique to Suboxone- I promise you, for every so many patients receiving prescriptions for benzodiazepines, stimulants, and a licit opiate for pain control, the same thing is also happening. You just donâ&#x20AC;&#x2122;t know which ones they are.) To minimize this, one takes the usual precautions of random office urine drug testing (also highly recommended for anyone seeking out stimulants and benzodiazepines in my practiceâ&#x20AC;Ś you might be surprised at what you find), pill counts (a bother and a

humbling reminder that simple math is long since distant for us in our education), utilization of the NCCSRS (NC Controlled Substances Reporting System that tracks all controlled substance prescriptions written in the state) and creative limitsetting. E.g., when someoneâ&#x20AC;&#x2122;s seeking an early refill in my practice and Iâ&#x20AC;&#x2122;m on the fence as to their reasons why, I give them the choice between an immediate refill but at a permanently reduced dosing, or the full dosing but only at the originally appointed time of runout; at the very least, they canâ&#x20AC;&#x2122;t do it very many times before they will be off of it. â&#x20AC;˘ Trust issues: See the aboveâ&#x20AC;Ś While the old adage about addicts has a lot of truth to it (Q:How do you know when an addictâ&#x20AC;&#x2122;s lying to you? A: Heâ&#x20AC;&#x2122;s moving his lips when he speaks.), it is also true that those who succeed in conquering their addictions usually do so only after multiple failed attempts. For a psychiatrist, itâ&#x20AC;&#x2122;s what we do- in trying to fathom peopleâ&#x20AC;&#x2122;s behavior and emotions and find ways to help them through and past them. For the primary care practitioner, there are undoubtedly more time pressures than the typical psychiatrist faces in working with such patients. But, for a great many addicts, their primary care physician may also be their only realistic avenue to treatment. And so, I would counsel the primary care provider whoâ&#x20AC;&#x2122;s contemplating taking on the prescribing of Suboxone in their practices to

not hesitate to give it a try, but to retain their reason about not taking on more patients than they can get to know personally over time. In my opinion, the ideal distribution of physicians to address the burgeoning societal problem of opiate addiction is not for a small cadre of them to carry the 100-patient maximum that the law allows, but rather for most physicians to be willing to carry the 30 or so that federal law wisely limits us to in that first year of certification. In summary, I would urge all psychiatrist and primary care physicians to consider becoming Suboxone prescribers. Opiate addition is a scourge that is arguably responsible for greater mortality than any other illnessespecially in our young adults, with ripple effects that also take more of a societal toll than any other illness. There is quite likely someone in your circle of family, friends, or acquaintances that is struggling silently with it- we just donâ&#x20AC;&#x2122;t know who they are due to the stigma of asking for help with it. (The fact that there are very few longterm addicts who have not lost multiple friends to opiate overdose is, for many, a major motivation to treatment.) And I have many times thought that when itâ&#x20AC;&#x2122;s all said and done, the patients above that Iâ&#x20AC;&#x2122;ve worked with are perhaps my greatest contribution to society over the decades-long practice that Iâ&#x20AC;&#x2122;ve had. So how many lives have you saved today? Â§

ajax and madness continued fuel to his suicidal furor by ridiculing him. Ajax eventually killed himself in spite of pleas of his wife (the antagonist) and several key Greek warriors. These actions seem strange and troubling to our modern forensic sensibilities. It was clear that Ajax intended to kill as many Greek as he could. Athenaâ&#x20AC;&#x2122;s deception is all that saved them. To understand all of these reactions we need to understand the mindset of the Greek warrior- death before dishonor. The rest of the play deals with the arguments over whether Ajax should receive a proper warriorâ&#x20AC;&#x2122;s burial. In spite of being one of the intended victims, Odysseus is moved to persuade Menelaus and Agamemnon (also intended victims) that Ajax should be properly buried. If not, his spirit is doomed to aimlessly wander about the earth for eternity. A proper burial assures his position in the Underworld. Neither are modern day exactly win-win solutions and for us they add a surreal nature to the play. What can we learn from the turmoil over the funeral ceremony? Clifford Geertz argued that changing cultural values undermine the meaning and function of many long established rituals. So where does the idea of culture change fit into this tragedy? Ajax and most of his intended victims were trapped by the ancient Homeric values of honor; vulnerability to

shame; an uncompromising need to revenge, and the routine humiliation of defeated enemies. Ajax personified the ancient warrior code. His actions were in keeping with the expectation of rage and fury, blood vengeance and violent reprisals. In contrast Odysseus represented reason, compromise and a new philosophy balancing reason with duty and violent emotions- Aristotle would elaborate on these over a century later. The goddess, Athena, had a more ambiguous role. Her diversion saved many Greek warriors but drove Ajax to madness and suicide. The peculiar piece for most of us: vengeance and suicide were expected, killing sheep was an act of madness. This brings us back to Geertz and a broader statement about the emergence of madness and changing cultural norms. Cross-cultural psychiatrists address some forms of mental illness (madness) as particular to a culture (culture bound). Another source of mental distress results from conflict and disintegration of traditional expectations about life and human relationships. It appears Sophocles favored the latter. In this play, Sophocles defined the emerging boundary between the Homeric warrior code and a contemporary Athenian models that focused on selfcontrol and co-operation. Ajax was locked into an anachronistic, dysfunctional

style of fighting that contrasted with the Athenian model. â&#x20AC;&#x153;Modern warfareâ&#x20AC;? relied more upon the group (phalanx) and less on the ideal of Homeric or heroic individual combat. Odysseus was the voice of the future- pragmatist who could negotiate and adapt (a sophist in later traditions). Athena was the marginalized character. Geertz might argue that the intense conflict over burial rights expressed the distress of these role/value changes. With a little imagination, the madness of Ajax was an anachronism- persisting ancient beliefs out of place in an evolving Greek culture. So does this tragedy enlighten us about madness and its boundary with modern heroes? Modern heroes seem to take an â&#x20AC;&#x153;unSophocleanâ&#x20AC;? worldview. Most Medal of Honor winners appear neither proud nor arrogant, claiming that â&#x20AC;&#x153;I didnâ&#x20AC;&#x2122;t do anything that everyone else in my shoes wouldâ&#x20AC;&#x2122;ve doneâ&#x20AC;?; or â&#x20AC;&#x153;I was just doing my jobâ&#x20AC;?. But these soldiers differ somewhat from mythologized Greek heroes. Next we will explore Hamlet: The Prince of Denmark. Shakespeareâ&#x20AC;&#x2122;s Hamlet struggled with a different set of changing values and social conflicts. He faced his fatherâ&#x20AC;&#x2122;s ghost who demanded blood vengeance but Hamlet presented a different set of philosophical and poetic inclinations. Â§

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he Wake County Medical Society – Community Health Foundation has two main programs: 1) Community Care of Wake and Johnston Counties – targeting the Medicaid-insured to help improve health and reduce patient care costs; and 2) the CapitalCare Collaborative (CCC) which was formed in April 2006 by local safety net clinics and hospitals to develop initiatives to improve the health of the county’s medically uninsured/underinsured. CCC goals are to: • Increase access to primary and specialty care • Reduce hospital visits • Assist with receipt of benefits for those who are eligible Previous Wake County Physician articles have focused on the CCC’s Project Access and Community Case Management Programs. In this issue, we will focus on their Homeless Service Programs which have seen a lot of expansion over the past year. In July of 2010, the CapitalCare Collaborative established its first program targeting the homeless population – SOAR (SSS/SSDI Access Outreach and Recovery). With the success of that program and with a growing awareness of the needs of the homeless population in Wake County, the CCC expanded in 2012 to form a more comprehensive and holistic team to engage, stabilize, and move homeless individuals toward self-sufficiency. Below is a brief overview of each of the program areas: SOAR: Since July 2010, the CapitalCare Collaborative’s SOAR staff has worked with chronically homeless clients with behavioral, cognitive, and physical impairments who may be eligible for disability benefits but who haven’t been able to qualify. The goal of the program is to expedite disability benefit approval for qualified applicants so that they can access income, health insurance (Medicaid), housing and critical support services. The SOAR Specialist meets clients where they are, including in the woods, at homeless shelters and clinics, etc. She completes client interviews and gathers information necessary for a comprehensive disability application, coordinates appointments, and accompanies clients to Social Security Administration and other agencies/healthcare appointments. Since program inception to present: o 90 chronically homeless individuals approved for disability and Medicaid o 75% now have housing (most had been living outdoors) o 100% have an established PCH o Medicaid reimbursement claims for the past year for the 69 approved through August 2012 total ~$550,000 o Average time it takes from submission to approval is 80 days

Joe (Homeless man)

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Serving as a Physician Volunteer K

erving the community as a physician volunteer can be a very rewarding opportunity. Volunteer needs are increasing on national, state, and local levels. The American College of Physicians maintains a volunteerism networking database to enable ACP members involved or interested in volunteerism and community service to connect with each other about volunteer opportunities, such as working in free clinics. To join the Volunteerism Network, please go to http://www.acponline. org/about_acp/committees/ volunteerism/volunteerism. htm. In Wake County, there are several hospitals, clinics, and organizations that are in need volunteer services. Below are some highlighted organizations that can use physicianâ&#x20AC;&#x2122;s services, both primary and specialty care.

The Alliance Medical Ministry, located near WakeMed Hospital, opened its doors in 2003 and currently provides a primary care medical home to more than 8,000 patients. Eligible patients include residents of Wake County without health insurance (including Medicare or Medicaid) that are at least 18 years old. At least one household member must be employed. Physician needs include both primary and specialty care. Most of their specialty needs are in the cardiac, orthopedic, ophthalmology, and ENT arenas.

Volunteers are typically needed during the day from 8:30 a.m. to 4 p.m. Needs are filled for half days or full days, and the patients are scheduled around the time that the physician will be there. For more information, please contact Elizabeth Daniel, Director of Outreach at 919-2503320 x422 or edaniel@ alliancemedicalministry. org. Shepherdâ&#x20AC;&#x2122;s Care Medical Clinic is located in Zebulon, NC and provides care for individuals between 18 and 64 years of age. Additionally, patients must live in Eastern Wake County (or overlapping areas of Nash, Franklin, or Johnston Counties) and must be within 200% of the poverty level. Having opened in 2010, they provide primary care and care for chronic conditions including asthma, diabetes, and hypertension. Outside referrals can be made for cardiac, gynecology, and orthopedic services. The clinic is open Monday, Wednesday, and Thursday from 9 a.m. to 5 p.m. as well as Tuesday from 9 a.m. to 1 p.m. For more information, please call Leona Doner, Executive Director at 919-4042474.

1961. To date, they have helped over 700,000 lives. They provide care for adult and pediatric patients, mental health services, dental services, and eye care services. Currently, they are seeking volunteers to help with primary care educational topics to promote healthy living, such as diabetes, hypertension, and asthma. Currently, the Raleigh Rescue Mission does not need primary care services for direct patient care; however specialty physicians might be able to see patients. To discuss volunteer needs, please contact Holly Cook, Director of Volunteer Ministry at 919-828-9014 x126 or hollyc@raleighrescue.org.

The Raleigh Rescue Mission is located in downtown Raleigh and began serving the homeless in

The Open Door Clinic, part of Urban Ministries of Wake County, was established in 1985 and provides comprehensive primary medical care in a medical home model to more than 5,000 patients. One of the purposes [continued on page 35] Z

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Pharmacogenomics and its Utility in Medication Dosing By Todd McKeon

n current medical practice, the approach of dosing medications is often “one size fits all”. Many patients are generally given similar doses of medication, without regard for the particular genetic make-up of the patient. In some cases the genetics may be irrelevant, but in others, a genetic difference may cause the same dose to have very different effects in two different patients. Pharmacogenomics is the branch of pharmacology which deals with the influence of genetic variation on drug response in patients. Much of how a drug functions in the body has to deal with how it is metabolized. A large number of drugs are metabolized by enzymes in the liver. Drug metabolism can be converting a medication to its active form or converting the active form to an inactive metabolite to be excreted by the body. The liver uses many enzymes to metabolize drugs including the Cytochrome P450 (CYP) enzymes. CYPs are the major enzymes involved in drug metabolism and bioactivation, accounting for about 75% of the total number of different metabolic reactions (1). Different families and subfamilies of the CYP enzymes metabolize specific drugs. Pharmacogenomic screening may allow clinicians to identify patients who have varying levels of metabolic enzymes and formulate patient specific dosing based on the k

results of the genetic profile (2). Genetic variations amongst patients can lead to different amounts of the metabolic enzymes present in the body. Medication dosage adjustments may be required based on the following scenarios: • Patients can over express a specific metabolic enzyme, which would lead to rapid metabolism of medications metabolized by that enzyme. Rapid metabolism would result in lower drug concentrations in the body and therefore less effect of the drug. A patient with this genetic variation would require a higher dose of the medication to achieve the same therapeutic effect as a patient who has the normal amount of the specific CYP enzyme. • Patients can also have genetic variations that would result in them either being deficient in the enzyme (slow metabolism) or not having the enzyme at all. A patient who is deficient in the specific enzyme required for their drug metabolism would not be able to efficiently metabolize the medication to its inactive metabolite to be excreted by the body. This could lead to a buildup of the medication in the body that could lead to toxicity. A patient with this genetic profile would require a lower dose of the medication to avoid potential drug toxicities. • Patients who receive medications that require CYP metabolism to become active,

who are deficient in that specific enzyme, would require higher doses of medication to achieve the same therapeutic effect as a patient who has the normal level of the metabolic enzyme. If the patient is totally lacking the enzyme, they would never be able to metabolize the medication to its active form and require a different medication for therapy Some medications used by patients with cardiovascular disease are Plavix (clopidogrel) and Coumadin (warfarin). Both clopidogrel and warfarin require metabolism in the body to have the desired effect. Therefore, the genetic make-up of an individual thus contributes to how effective, or ineffective, these drugs are. Genetic variation can also affect dosing for medications used to treat HIV, Cancer, Heartburn, and mental health. Clopidogrel is metabolized by an enzyme called CYP2C19 (2). This enzyme produces a metabolite of clopidogrel that has the pharmaceutical effect. However, 25-30% of patients have a variant of this enzyme that does not effectively activate clopidogrel. These patients have a 53% increase in the risk of death from cardiovascular causes (3). This was based on a clinical study published in the New England Journal of Medicine, where those that were slower metabolizers of clopidogrel had a decrease of 32.4% reduction of the active metabolite in their

body (3). The active metabolite of clopidogrel is not easily measured in clinical practice and therefore a pharmacogenetic screen maybe instrumental in optimizing a patient’s therapy. Warfarin is metabolized primarily by an enzyme called CYP2C9 (4). But again, depending on a person’s genetic make-up, this could either have an enhanced or reduced effect (2). The effectiveness of warfarin can be measured relatively easy by a blood test, INR, and dosages adjusted accordingly. Pharmacogenetic screening may not be as useful in patients initiating therapy on warfarin especially in an inpatient setting when they are getting routine blood work (2). The utility of pharmacogenomic screening in clinical practice has yet to be fully elucidated. Many pharmacogenetic tests are available, but testing has not been recommended for most drugs (2). The FDA strongly

recommends pharmacogenetic screening for only a few clinical scenarios, mostly in HIV treatment (2). The cost of pharmacogenomic testing is quite high and there is a lack of clinical data to support its use in improving clinical outcomes (6). There is a huge potential for pharmacogenomics to greatly impact healthcare by providing patients with personalized medication therapy. For pharmacogenomics to be truly successful within the clinic there must be increased clinical trial evidence to support improvement in clinical outcomes and recommendations for providers on how to adjust therapy based on genotyping results. §

Works Cited 1. Cytochrome P450. Wikipedia. [Online] [Cited: Jan 28, 2013.] http://en.wikipedia.org/wiki/ Cytochrome_P450. 2. Cleveland Clinic Journal of Medicine . Kitzmiller, Joseph. 4, April 2011, Vol. 78, pp. 243-257. 3. Clopidogrel. FDA. [Online] [Cited: 1 28, 2013.] http://www. accessdata.fda.gov/drugsatfda_ docs/label/2011/020839s055lbl. pdf. 4. NEJM. JL, Mega. 4, Jan 2009, Vol. 360, pp. 354-62. 5. Coumadin. FDA. [Online] [Cited: 1 28, 2013.] http://www. accessdata.fda.gov/drugsatfda_ docs/label/2011/009218s107lbl. pdf. 6. British Journal of Clinical Pharmacology. Shah, Rashmi. 4, 2012, Vol. 74, pp. 698-721.

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Brief on 2012 American Academy of Neurology Migraine Prevention Guidelines By Rachel Smith Background In our fast-paced, stress-filled society, it is no wonder that every 10 seconds someone in the U.S. goes to the emergency room with a headache or migraine.(4) It has been estimated that over 10% of our population suffers from migraine- approximately 18% of women and 6% of men. What is disheartening, however, is that nearly half of migraineurs are diagnosed and a large majority does not seek medical care for their pain. With migraine being such a prevalent condition, it is important for primary care providers, neurologists, and all medical professionals to be aware of the treatment guidelines and best practices for helping migraine patients achieve symptom control and improved quality of life. In 2000, the American Academy of Neurology (AAN) in conjunction with the U.S. Headache Consortium published guidelines on the prevention of migraine. Since that time, new data from recent clinical trials has been published, leading the AAN to issue the 2012 guidelines update for migraine prevention in adults.

About the Guidelines Many of the recommendations in the 2012 update regarding migraine prophylaxis have not changed significantly since 2000. The authors did reformat the structure of the guidelines, however, to reflect recommendations based solely on clinical efficacy and not side effects or tolerability. Thus, in the new update the authors have ranked evidence according to strength of trial dataallowing clinicians to weigh the risks/ benefits of individual treatments on their own. The AAN clearly delineates the criteria for ranking of evidence for their recommendations. Briefly, they require that ≥2 well-designed, Class I trials support the use of a drug in order to achieve a Level A recommendation. Levels B and C require fewer high-quality studies and Level U is given to drugs with conflicting data and low-quality evidence supporting their use. The guidelines recommend that migraine prophylaxis be considered (based on expert opinion) for the following scenarios: patients with contraindications to acute treatments, patients experiencing frequent migraines that interfere with daily activities, failure or overuse of acute therapies, and presence of uncommon migraine conditions.(1-3) [continued on page 21]

Regarding first-line therapies (1-3) Since 2000, propranolol, divalproex sodium, and timolol have remained Level A medications for prophylaxis. In addition to these well-established treatments, the authors have also ranked metoprolol and topiramate with Level A recommendations for use. Please see figure for proposed treatment

While several drugs were upgraded to higher levels in the new guidelines, there were also a few drugs down-graded due to lack of quality evidence and conflicting data. Some of the drugs down-graded were amitriptyline to Level B, gabapentin to Level U, and verapamil to Level U. Although these guidelines provide information on effective prophylactic options, evidence is limited regarding duration of treatment and combination therapy options for migraine prevention. It should also be noted that separate guidelines exist for prophylactic use of NSAIDs & herbals and for acute treatment strategies related to migraine (which are not discussed here). Regardless of what medication is chosen for prophylactic therapy, several general principles apply: (1) make sure to titrate dose slowly while monitoring side effects and efficacy; (2) have the patient keep track of headache frequency, severity, and duration in home headache diary; (3) make an effort to choose medications that will not exacerbate comorbidities or precipitate migraine attacks; (4) always encourage patients to identify and avoid migraine triggers and to follow a healthy lifestyle. §

Note: For the complete version of the 2012 Guidelines Update, as well as access to patient education materials, please refer to the following website: http://www.aan.com/practice/guideline/index. cfm?fuseaction=home.welcome&Topics=16&keywords=&Submit=Search+Guidelines

References 1. Silberstein SD et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45. 2. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidencebased review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000 Sep 26;55(6):754-62. 3. Ramadan NM et al. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management for Prevention of Migraine. Available at: http://www.aan.com/ professionals/practice/pdfs/gl0090.pdf Accessed Feb 2013. 4. Migraine Research Foundation. Accessed online Feb 2013: http://www.migraineresearchfoundation. org/fact-sheet.html

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homeless engagement team continued Homeless Engagement and Community Stabilization: A nurse and a peer outreach specialist conduct street outreach to people living on the streets to get them connected with medical care and behavioral health (BH) services and accessing needed medications. Another nurse and a case coordinator work primarily at South Wilmington Street Center (men’s shelter) and the Helen Wright Center (women’s shelter) facilitating respite services for homeless men with acute medical and BH needs. They work to connect these individuals to longer term services (medical and BH), medication, and housing – following them for up to a year to ensure that they maintain their housing and support services. This team collaborates on a regular basis with law enforcement, hospitals, shelters, BH providers, and others to address the range of needs facing the estimated 2,500 homeless individuals in Wake County. The impact they are already having is significant in terms of getting long-term homeless individuals off the streets and into care – and living with stability as a result of greatly improved mental and physical health conditions. As of the end of December 2012, there were: o o o o

190 Engaged 47 Enrolled in CSP 74 connected with Primary Care 49 connected with MH services – 29 have maintained MH services for 3+ months o 60 placed in housing – 17 have maintained housing for 3+ months

Sam’s Story

or the past nine years, ‘Sam’ has spent each night in his native Raleigh sleeping in abandoned cars, sheds, the woods, and a garage of a friend. During that time, Sam was sporadically mentioned by friends and his two ã

homeless brothers to the CapitalCare Homeless Engagement RN during her years of outreach and service to homeless men and women. Ongoing connection and service provision with Sam without a phone or permanent place to live were a sizable challenge. The last six months, however, saw Sam encounter significant loss and hardship as he learned that his brother had been discovered dead in a vacant house, and that a very close friend with cancer whom he had assisted care giving also had died. These traumatic events were the catalyst that at last enabled Sam to accept the assistance of the Homeless Engagement RN. Together, Sam and the HEN set healthy and achievable goals, readily coordinated his medical care with Horizon Health Care, and successfully connected with assistance for disability benefits through the CapitalCare SOAR Specialist. In November 2012, Sam was approved for SSI benefits through the SOAR program. This breakthrough enabled the CapitalCare HEN and SOAR Specialist to successfully approach a landlord who owned a few rental properties in Garner. After the team advocated on Sam’s behalf, he was approved to rent one of these properties—his first permanent home in more than nine years! Move in day found an ecstatic Sam, surrounded by groceries, household items, and furnishings obtained through the CapitalCare Team efforts in accessing community resources. Sam is currently saving for a scooter for increased independence, self-sufficiency, and access to his needs. Sam regularly continues his connection by phone and in person with the CapitalCare Team. Clark’s Promise: Helping the Homeless one Person at a Time. Go to www.clarkspromise.org to view video. Clark’s Promise is an organization that helps the homeless in Raleigh NC through engagement nursing. To learn more visit www.clarkspromise.org

diabetetes standards and care continued