CAFP ASA Guide 2013 by California Academy of Family Physicians

May 3-5 â&#x20AC;˘ San Francisco

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65 th A nnual S cientific A ssembly May 3-5, 2013 | Marriott Marquis | San Francisco CA

2013 Committee on Continuing Professional Development and Curriculum Development Teams The chair and members of CAFP’s Committee on Professional Development work throughout the year with CAFP curriculum development teams to ensure that our continuing medical education activities are of the highest quality, providing clinical and practical relevance, and are presented free of promotional bias. If you have any comments or suggestions, they would be happy to hear from you. Our thanks to them for their commitment to the highest quality continuing medical education. May 3-5 • San Francisco

Contents

Hotel Information..................................................... 7 Leadership Letter...................................................... 8 Complete Schedule of Events................................... 9 Meeting and Program Information......................... 11 CAFP and CAFP Foundations Industry, Corporate and Foundation Partners............................................... 13 Award Winners....................................................... 16 Special Recognition................................................ 19 CAFP Foundation.................................................... 20 Family Physicians’ Political Action Committee....... 21 Quality, Practice and Performance Improvement Member Anniversaries........................................... 23

David E. J. Bazzo, MD, Chair Thomas C. Bent, MD Ashley Christiani, MD Christopher Flores, MD Carol Havens, MD Tipu Khan, MD Lenny Lesser, MD Michael Potter, MD Martin Quan, MD

Lee Ralph, MD William Woo, MD

CME Scorecard....................................................... 25

CAFP CME Staff: Jerri Davis, CCMEP Cynthia Kear, MDiv, CCEMP Shelly Rodrigues, CAE, CCMEP, FACEHP

Board of Directors and Staff Directory................... 28

The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

Past Presidents....................................................... 27 Saturday Sessions................................................... 34 Sunday Sessions................................................... 191

Syllabus

Saturday Sessions................................................... 34 Sunday Sessions................................................... 191

CAFP • 1520 Pacific Avenue • San Francisco, CA 94109 • Phone 415 345 8667 • E-mail cafp@familydocs.org • www.familydocs.org May 3-5 • San Francisco

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Interested applicants should submit a CV to: Robert D. Allen, M.D. Program Director, KDHCD Family Medicine Residency 400 W Mineral King • Visalia, CA 93291 Email: rallen@kdhcd.org Phone: 559.624.5213 Fax: 559.625.7559

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The California Hospital Medical Center/University of Southern California amily Medicine Residency Program affiliated with Faculty from the USC Keck School of Medicine of USC is seeking an ABFM Board Certified physician to join the Program as USC Faculty. The CHMC FMRP, an unopposed 8-8-8 Program, was established in 1984, and has been fully accredited since its inception. This exciting and challenging full time opportunity includes responsibilities in the areas of in-patient care, ambulatory (continuity clinic) care, obstetrics, and private practice. Your role(s) will include direct patient care, administrative/scholarly time, teaching, and supervision of the Program's Residents You will also be involved with the various paraprofessional educational Programs. California Hospital Medical Center, a major teaching hospital, is a 316-bed, not-forprofit, acute care, safety-net, research and teaching facility which is a part of Dignity Health, a health care organization which provides full service compassionate care at their more than 40 urban and rural hospitals in California, Arizona and Nevada. California Hospital Medical Center is committed to serving its underserved community. California Hospital Medical Center provides a myriad of tertiary care services, and has specialties in areas such as comprehensive women's (Los Angeles Center for Women's Health) and children's services (including nurse-midwifery services and a teen-parent clinic), 24 hour emergency services (including a sexual assault and domestic violence response team and a Level II Trauma Center), family health services (including the USCEisner Family Medicine Center), Hope Street Family Center and the Donald P. Loker Cancer Center. In our urban community, residents of all ages and backgrounds have access to primary care, preventive treatment, clinical support, chronic disease management, trauma services, and a host of medical and therapeutic specializations. Our residents' primary training site is the FMC. The USC-Eisner Family Medicine Center is staffed by Eisner employees and USC faculty; it is a federally qualified nonprofit community health center dedicated to improving the physical, social, and emotional wellbeing of people in the communities we serve, regardless of income. As an FQHC, we are able to see patients of all ages, regardless of immigration status. The selected candidates will have completed an ACGME approved Family Medicine Residency Program, have a CA license, a current DEA, and be Board Certified We value your experience as an active Faculty in an ACGME FMRP; we will look at both new and experienced physician candidates. Our position provides an academic appointment, research opportunities, and a very competitive compensation and benefit program.

Thank you in advance for your interest. Please submit your curriculum vitae to: fmrp@usc.edu

PHYSICIAN — FULL-TIME OR PART-TIME for MED7 Urgent Care Centers. Urgent care clinics are located in Roseville, Carmichael, Folsom & North Sacramento. Board Certified or Board Eligible in family practice or emergency medicine. All shifts 9am to 9pm. Full time is 13 shifts per month. We offer our full time physicians the following: full malpractice coverage, medical & dental coverage at no cost for the physician & any dependents, disability policy & we have a simple IRA you can contribute to with 3% matching. Part time is 6 to 8 shifts per month. There is no call. There is no tail coverage that needs to be purchased should you leave our employment. We have a single policy that continues on after you leave. If something were to arise here after you left our employment, you would be covered. For more information about MED7 and our clinics please visit our website: www.med7.com We offer an attractive compensation package. Contact Merl O’Brien,MD, at: (916) 483-5400, ext.111; or email CV to: sherry@med7atwork.com.

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PHYSICIAN – FAMILY MEDICINE Vista Community Clinic located in North San Diego County Seeking: Full-time, part-time and per diem Family Medicine Physicians. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Contact Us: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760-414-3702 65th CAFP Annual Scientific Assembly

Marriott Marquis Hotel – Home to the ASA The CAFP’s events are all on the Golden Gate Level, down one floor, via escalator, from the Main Lobby. Room Assignments: Registration Computer Camp CAFP Central Staff Office/Speaker Room Main Lecture Hall All Member Game Night and “2 Minutes/2 Slides/2 Questions” SAMS Groups Maternity Care Pain Management Workshops Contraception Update & IUD Insertion Dermoscopy ICD-10 Seminar Focus Groups

Golden Gate Foyer Golden Gate Foyer Golden Gate Foyer Willow Room Golden Gate A-B Golden Gate A-B

Golden Gate 3 Golden Gate 2

Golden Gate 1 Juniper Pacific H Pacific I and J

Going Green

CAFP is doing its best to make this meeting “Green.” This means more than just the environment – we’ve made a few changes we hope you’ll appreciate: • • •

•

Our food and beverage selections have changed Our selections feature a menu lower in fat and calories, higher in grains, veggies, and fruits. Our materials can be recycled and the Marriott is committed to “green”: • The 2013 Program Book is electronic. We’ll have a flash drive for you and it is available online for download. • All printed materials are recyclable. We hope you’ll drop items you don’t need in bins. • Badges can be recycled – leave them in the bin at the Registration desk – or take them with you for next year’s meeting! • We’ve got a ribbon bank this year – if you want a ribbon to show your Foundation or PAC support, grab one, if you want to go ribbonless, that’s OK too. • The evaluation form is online this year – easy to access, and you print out your CME certificate when you complete the evaluation. • The ASA Shopping bag can be thrown in your trunk and used at the grocery! Among other green activities, the Marriott also: • Composts the food from its kitchen, has changed 95% of its lights to energy-efficient, compact fluorescent lights, has installed low flush toilets, and has upgraded thermostats for energy savings • Recycles all paints and solvents, ballasts and fluorescents bulbs, and kitchen grease to make bio-diesel

May 3-5 • San Francisco

Leadership Letter May 4, 2013

Dear Colleague: It is our honor to welcome you to the 65th Annual Scientific Assembly of the California Academy of Family Physicians. Learning with one another and from one another is what family physicians do – just being together provides a sense of renewal from which we all benefit. This meeting is undoubtedly the premier family medicine CME program in our state – and one of the very best values for your CME dollar. You’ve made a wise and costeffective decision to attend. We all need a break from the pressures of our everyday practices and this is a great one. Your Academy has made every effort to bring high you quality CME that meets your needs – especially as you may be facing the new Maintenance of Certification requirements for certification or recertification by the American Board of Family Medicine. The program you are about to experience marries clinical CME content to the requirements set forth by the ABFM, based on a professional needs assessment and identification of key education gaps. It mixes lectures, cases, audience response, learning assessments, hands-on workshops, patient videos and more. It focuses on the families you see in your practice every day! You can receive up to 18.5 evidence-based Prescribed Credits at extremely low cost, in one of California’s most beautiful cities, San Francisco. We’ve planned a full schedule for you – from lectures and panels to SAMS groups, hands-on workshops and an ICD-10 seminar. We’ve invited some of your favorite faculty members, and are thrilled to introduce new presenters as well. We’ve included the perennial favorite “Two Minutes, Two Slides, Two Questions” … this year led by our family medicine residents! We’re very happy that you’ve chosen to attend and look forward to the opportunity of meeting you during the next two days. Take advantage of this time to speak with your colleagues and share your experiences. Sincerely, Steve Green, MD Mark Dressner, MD CAFP President CAFP President-elect

From the top: Steve Green, MD, Mark Dressner, MD David Bazzo, MD

David Bazzo, MD Chair, CAFP Committee on Continuing Professional Development

65th CAFP Annual Scientific Assembly

ASA | Schedule of Events â&#x20AC;&#x201D; Friday-Saturday May 3-4 Friday, May 3 Registration

Registration

12:00-1:00 pm

Golden Gate Foyer

Norma Jo Waxman, MD

Workshop: Contraception Update and IUD Insertion Training (Madison Carmichael)

1:00-3:30 pm

Golden Gate 1

Michael Van Buskirk, MD

Workshop: Expand your Practice: Dermoscopy for Family Physicians

1:00-3:30 pm

Juniper

Tipu Khan, MD

SAMS: Maternity Care

1:00-5:00 pm

Golden Gate 3

Lauren Simon, MD

SAMS: Pain Management

1:00-5:00 pm

Golden Gate 2

Saturday, May 4 Registration David Bazzo, MD

Registration and Continental Breakfast Opening Remarks and Welcome

7:00-8:00 am

Golden Gate Foyer

8:00-8:30 am

Golden Gate A-B

Reid Blackwelder, MD Keynote: Setting the Stage for 8:30-9:30am Golden Gate A-B AAFP President-Elect the Family of Family Medicine Refreshment Break Geoffrey Leung, MD and Releasing the Migraine Vise: 9:45-10:45 am Catherine Sonquist-Forest, MD Not your Typical Headache Program (Camille Carmichael)

Golden Gate A-B

Chris Flores, MD Pondering, Wandering and other 10:45-11:30 am Dementia Dilemmas (Ted and Esther Young) Refreshment Break Grab Your Lunch and Get Back to Work! David Bazzo, MD and Carol Havens, MD ER/LA Opioid REMS: 12:00-1:30 pm Achieving Safe Use While Improving Patient Care Refreshment Break Marshall Kubota, MD HIV Prevention and Screening 2:00-2:30 pm (Mark Carmichael)

Golden Gate A-B

George Kent, MD

Hep C: Asking the Right Questions (Chris Lee)

2:30-3:00 pm

Golden Gate A-B

Lee Ralph, MD Break David Schneider, MD

Tips for TBI Screening (Anthony Jones)

3:00-3:30 pm

Golden Gate A-B

Busting Autism Myths 4:00-4:30 pm (Conner and Ethan Carmichael-Perez)

Golden Gate A-B

Lauren Simon, MD

Weight Issues for Kids (Jenae and Sean Jones)

4:30-5:00 pm

Golden Gate A-B

Mark Dressner, MD

Best Practices for Secondary 5:00-5:30 pm Stroke Prevention (Kwan Lee)

Golden Gate A-B

All-Member Game Night Two Minutes, Two Slides, Two Questions

The Residents will lead this audience 6:00-7:30 pm participation educational session. Raul Ayala, MD will preside.

Golden Gate A-B

All lectures are included in the registration price and do not require pre-registration. All attendees receive complimentary admission to the Sunday workshop. The Group SAMS required additional payment and pre-registration. May 3-5 â&#x20AC;˘ San Francisco

ASA | Schedule of Events — Sunday, May 5 Registration

Registration and Continental Breakfast

David Bazzo, MD Ashby Wolfe, MD Carla Kakutani, MD Patrick Joseph, MD Michael D. Hogue, PharmD

Opening Remarks 8:30-9:00 am Sacramento Report From FP-PAC

Golden Gate A-B

Building an Adult 9:00-10:00 am Immunization Practice: The Primary Care Physician’s Role in Disease Prevention (Marta Perez)

Golden Gate A-B

Bo Greaves, MD Improving Diabetes Outcomes: 10:00-11:00 am Chris Sadler, PA-C Placing the Patient at the Center (Robert Carmichael) Refreshment Break

Golden Gate A-B

William Woo, MD

Cancer Screening in Family Medicine 11:30-12:15 pm (Sarah Jones)

Golden Gate A-B

Paul Doghramji, MD Karl Doghramji, MD David Bazzo, MD Mary Jean Sage

Restless Legs Syndrome—Causes, 12:15-1:15 pm Consequences and Clinical Management (Sally Carmichael)

Golden Gate A-B

Closing Remarks Workshop: ICD-10 and what you need to know to change the way you code!

Golden Gate A-B Pacific Room H

7:00-8:00 am

1:15-1:30 pm 1:30-3:30 pm

Golden Gate Foyer

65th CAFP Annual Scientific Assembly

Meeting and Program Information CAFP’s 65th Annual Scientific Assembly is a launching pad for several of CAFP’s new national initiatives – you get the information first! The clinical sessions will be presented in a variety of formats; each will be based on evidence-based practice recommendations and will include case-based learning. Sessions will be presented with music, in a conversation style with two faculty members, or with an audience response system. Faculty members were selected from a pool of your favorite presenters. You won’t want to miss our Keynote address by Reid Blackwelder, MD, AAFP President-Elect. Clinical Sessions Our main stage program consists of 14 sessions that will give you up-to-date information on research findings and treatment indications on a variety of diseases and important issues for your practice. All clinical sessions take place in the Golden Gate A-B Ballroom. At the end of each session, five minutes will be provided for questions from the floor. Line up behind the microphone in the aisle nearest you. One question per person please. Faculty will be available in the Golden Gate Foyer after Saturday’s 3 x 30 sessions for questions. SAMs Groups, Hands-On Workshops and an ICD-10 Seminar We’ve planned two SAMs group sessions – pre-registration was required. These sessions will be presented in Golden Gate 2 and 3; break refreshments and materials will be provided. CAFP will click “Submit” for you and the first portion of your SAMs will do complete. Two hands-on workshops are slated for Friday afternoon – they require a registration fee, but on-site registration is available as long as space permits. They’ll be held in Golden Gate 1 and Juniper. An ICD-10 Seminar will take place on Sunday afternoon – divided into didactic and round table discussion. The Sunday session requires a small registration or fee. Please join us in the Pacific H Room (4th Floor). Special CME Reporting Form for CAFP Members You can quickly report your CME by going online to AAFP – www.aafp.org/mycme – and entering the credits directly – no middle person! We have also included a CME Scorecard for you to use to keep track of the sessions you’ve attended.

May 3-5 • San Francisco

Use it to report your CME to the AAFP and keep it for your records. CME Certificate and Meeting Evaluations You will receive an electronic CME Certificate for this meeting. To receive your CME certificate, you must complete your Annual Scientific Assembly evaluation form. Complete your evaluation by: Clicking on the Evaluation Icon on any Computer Camp laptop. It will take you directly to the evaluation form. OR Clicking on the evaluation link on CAFP’s Web site: www. familydocs.org/professional-development/ASA.php, which can be accessed from our computer camp or when you get home. The Computer Camp will be open after the last session on Sunday; stop by and complete your evaluation before you leave the meeting. Please take a few moments to fill out the meeting evaluation – this information is extremely important. Your opinions on topics and speakers provide the best source of information for planning the program of future Scientific Assemblies. Questions? Ask any CAFP staffer. Thank you! Continuing Medical Education Credit The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CAFP takes responsibility for the content, quality, and scientific integrity of this CME activity. The CAFP designates this activity for 18.5 AMA PRA Category 1 Credits TM. This meeting has been reviewed and approved by the American Academy of Family Physicians for 18.5 Prescribed credits. AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 Credit TM toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed credit, not as Category 1.

Registration Location: Golden Gate Foyer Hours: Friday, May 3, 2013 12:00 pm – 4:00 pm Saturday, May 4, 2013 7:00 am – 3:00 pm Sunday, May 5, 2013 7:00 am – 1:30 pm CAFP Central – Member Services Location: Golden Gate Foyer Hours: Saturday, May 4, 2013 7:00 am – 3:00 pm Sunday, May 5, 2013 7:00 am – 1:30 pm

breakfasts and lunch. Guest breakfasts and lunch require an additional fee, which can be paid onsite at the registration area. We’ll also have a list of nearby restaurants for your dining pleasure, and the hotel has a Starbuck’s in the lobby.

Please stop by CAFP Central. CAFP staff members and leaders will be available during the morning sessions. We’re here to answer questions, provide information regarding member benefits, help you get more involved, and simply to say “Hi.” You can learn more about CAFP’s member services and upcoming events, find out about leadership opportunities, and peruse practice management resources developed by the Academy. Computer Camp Location: Golden Gate Foyer Hours: Saturday, May 4, 2013 7:00 am – 4:00 pm Computer and printing access are available in our Computer Camp in the Golden Gate Foyer. You can check e-mail, print syllabus materials and boarding passes, and complete your meeting evaluation. Only attendees with name badges may use the Computer Camp. Breakfasts, Lunches, Snacks and Beverages Continental breakfasts and light refreshments will be offered in the Golden Gate Foyer, with seating in the Golden Gate Rooms 1-3 for attendees only – beverage service will be available 7:00 am – 12:30 pm. Saturday box lunches will be available at Noon, in the Golden Gate Rooms 1-3 – we’ll have working/ learning lunches. No lunch service on Sunday, but we’ll have a late refreshment break on Sunday. Every attendee and paid guest (tickets will be provided for paid guests) are invited for

Breakfast Saturday and Sunday 7:00 am – 8:00 am Golden Gate Rooms 1-3 Beverage Service Saturday and Sunday 9:00 am – 11:00 am Golden Gate Rooms 1-3 Refreshment Break Saturday and Sunday Saturday 11:00 am – 11:30 am 2:00 pm – 2:30 pm Golden Gate Rooms 1-3 Lunch Saturday 12:00-12:30 pm Pick-up Golden Gate Rooms 1-3 CAFP All-Member Game Night and “Two Slides/Two Minutes/Two Questions” The CAFP New Physicians Social has become an All-Member Game Night event! Everyone is invited. We’ve also changed the Battle of the Residents this year – our residents will be leading a “Two Slides/Two Minutes/Two Questions” session during the Game Night. Lots of fun and CME credits! Join us at 6:00 pm, Saturday, in the Golden Gate A-B Ballroom for the events. We’ll have “game food,” a kids’ activity table, and more! CAFP Foundation Silent Auction Don’t miss the CAFP Foundation’s 8th Annual Silent Auction! Bidding for auction items will be open Saturday, May 4, 2013, with final bids placed at 7:30 pm at the End of the All-Member Game Night event. Notice of winning bids will be on Sunday morning and winner can collect their items between 8:00 am1:00 pm on Sunday. By bidding, you will help support California’s medical students and family medicine residents. A big CAFP-F thanks!

65th CAFP Annual Scientific Assembly

Continuing Medical Education Credit and Disclosure of Conflict of Interest The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CAFP takes responsibility for the content, quality, and scientific integrity of this CME activity. CAFP requires all Board members, committee members, staff, planners and faculty members who have the potential to influence content to make a declaration of Interest. All disclosure forms are reviewed and potential conflicts of interest identified, managed and resolved using a process adopted by the CAFP’s Committee on Continuing Professional Development. Any individual who refuses to (or chooses not to) disclose relevant financial relationships will be disqualified from participating in any portion of this activity – from planning to presenting.

Individual

Role

Disclosure

David E. J. Bazzo, MD, Chair

Planner/Faculty

Nothing to Disclose

Thomas Bent, MD

Planner

Nothing to Disclose

Christopher Flores, MD

Planner/Faculty

Nothing to Disclose

Carol Havens, MD

Planner/Faculty

Nothing to Disclose

Lenny Lesser, MD

Planner

Nothing to Disclose

Lee Ralph, MD

Planner/Faculty

Nothing to Disclose

William Woo, MD

Planner/Faculty

Nothing to Disclose

Norma Jo Waxman, MD

Faculty

Scientific Advisory Board of Medicine 360, a not-for-profit organization.

Michael Van Buskirk, MD

Faculty

Nothing to Disclose

Tipu Khan, MD

Faculty

Nothing to Disclose

Lauren Simon, MD

Faculty

Nothing to Disclose

Reid Blackwelder, MD

Faculty

Nothing to Disclose

Geoffrey Leung, MD

Faculty

Nothing to Disclose

Catherine Sonquist Forest, MD

Faculty

Nothing to Disclose

Marshall Kubota, MD

Faculty

Honoraria from ViiV and Gilead Sciences, both makers of HIV therapeutic options

George Kent, MD

Faculty

Nothing to Disclose

David Schneider, MD

Faculty

Nothing to Disclose

Mark Dressner, MD

Faculty

Nothing to Disclose

Patrick Joseph, MD

Faculty

Nothing to Disclose

Michael Hogue, PharmD

Faculty

Honoraria and consultant/advisory board member for Pfizer

Bo Greaves, MD

Faculty

Nothing to Disclose

Chris Sadler, PA-C

Faculty

Consultant and honoraria from Amylin/Lilly, Amylin and Novo Nordisk

Paul Doghramji, MD

Faculty

Nothing to Disclose

Karl Doghramji, MD

Faculty

Consultant for UCB and Elan, stock in Merck

Mary Jean Sage

Faculty

Nothing to Disclose

Shelly B. Rodrigues

Staff

Nothing to Disclose

Cynthia Kear

Staff

Nothing to Disclose

Jerri Davis

Staff

Nothing to Disclose

May 3-5 • San Francisco

CAFP and CAFP Foundations Industry, Corporate and Foundation Partners This year’s exceptional value in CME is possible because of the corporations and foundations that generously provide grants and donations that help to underwrite the costs of CAFP and CAFP Foundation educational programs and other efforts.

quality, independent medical education for healthcare professionals and patients that resolves unmet medical needs, fosters clinical excellence, and measurably improves health outcomes in areas of strategic focus to BIPI.

Absolutely NO strings are attached to any of these support grants — control of ALL educational content and speaker selection remains entirely with CAFP. Educational grants are provided to ensure that important educational information is made available to family physicians.

Bristol-Myers Squibb is a global BioPharma company firmly focused on its mission to discover, develop and deliver innovative medicines that help patients prevail over serious diseases. BMS supports a clean and healthy environment and subscribe to policies and practices that merit the trust and confidence of our society. Bristol-Myers Squibb’s Independent Medical Education (IME) mission strategically supports IME activities in disease areas of focus that address recognized gaps in healthcare delivery in order to improve patient care. Independent Medical Education supports activities designed to enhance the professional skills and knowledge of health care professionals, when the program is independently developed and conducted by a qualified medical education provider. Supported programs must be objective, balanced, and scientifically rigorous.

The companies listed below have provided support of family medicine and the ASA by making financial grants and/or donations to the meeting. CAFP wishes to acknowledge them for their support. Please thank your local representatives for recognizing the value of family medicine. 3Gen manufacturers the DermLite brand of skin imaging device. Allergan is a global technology-driven multi-specialty health care company focused on developing and commercializing innovative pharmaceuticals, biologics and medical devices that enable people to live life to its greatest potential — to see more clearly, move more freely, and express themselves more fully. Asante Communications, LLC, is a full service medical communication company specializing in physician and patient education. Utilizing proprietary research methodologies, the Asante team of scientists, writers and strategists identifies gaps in clinician knowledge and practice, facilitating the development of needs appropriate education under the guidance of the Accreditation Council for Continuing Medical Education. Partnering with leading academic institutions and faculty, we integrate the latest insights into disease management with comprehensive scientific and clinical data, creating coherent educational platforms. Asante delivers content across all relevant print, live, video and web-based distribution channels, each shaped by an expert understanding of adult learning principles. Based in New York City, the company is managed by veterans of the healthcare communications industry. Bayer HealthCare, a subgroup of Bayer AG with annual sales of EUR 18.6 billion (2012), is one of the world’s leading, innovative companies in the healthcare and medical products industry and is based in Leverkusen, Germany. The company combines the global activities of the Animal Health, Consumer Care, Medical Care and Pharmaceuticals divisions. Bayer HealthCare’s aim is to discover, develop, manufacture and market products that will improve human and animal health worldwide. Bayer HealthCare has a global workforce of 55,300 employees (Dec 31, 2012) and is represented in more than 100 countries. Boehringer Ingelheim is proud to provide Medical Grant support for specific independent educational activities for healthcare providers and patients that may translate to better management of disease and improvement in patient safety and population health. The Medical Grants Education Department is committed to supporting innovative, high

The Collaborative on REMS Education (CO*RE), a multidisciplinary collaboration of 10 Partners and two cooperating organizations, have designed a core curriculum based on needs assessment, practice gaps, clinical competencies, learner self-assessment, with shared tools, resources, and outcomes to meet the requirements of the FDA REMS Blueprint to provide effective prescriber- focused education on the safe and effective prescribing of ER/LA opioids to safely manage pain. Gilead was founded in 1987 in Foster City, California. In just over 20 years, Gilead has become a leading biopharmaceutical company with a rapidly expanding product portfolio, growing pipeline of investigational drugs and approximately 4,500 employees in offices across four continents. Gilead supports independent medical education activities that enhance and expand medical knowledge and skills for a range of healthcare professionals in accordance with applicable laws and regulations. The activities funded through medical education grants must comply with the Accreditation Council for Continuing Medical Education Guidelines and the PhRMA Code on Interactions with Healthcare Professionals. National Foundation for Infectious Diseases (NFID) is a non-profit, taxexempt 501(c)(3) organization founded in 1973 dedicated to educating the public and healthcare professionals about the causes, treatment, and prevention of infectious diseases. NFID carries out its mission by: providing education to the public and healthcare professionals; supporting research and training in infectious diseases; building coalitions; and honoring scientific and public health achievement, legislative contributions, and philanthropy in infectious diseases. For additional information, visit www.nfid.org. Novo Nordisk uses recombinant DNA technology to make innovative products for people. In 1923, they first marketed insulin for commercial use; today, they offer a comprehensive line of human insulin and

65th CAFP Annual Scientific Assembly

insulin analog products. Novo Nordisk created the world’s first insulin pen device, and is now a world leader in production and distribution of these revolutionary insulin delivery systems. Defeating diabetes with innovation. That’s the goal of Novo Nordisk. Pfizer Medical Education Grants support high-quality activities, educational interventions and materials to improve patient care and health outcomes. These grants are never related to, or otherwise conditioned upon the past, present or future prescribing, purchasing, or recommending of Pfizer products, and is conducted in accordance with the recommendations and mandates of the Office of the Inspector General’s Compliance Program Guidance for Pharmaceutical Manufacturers, the Accreditation Council for Continuing Medical Education Guidelines, and the PhRMA Code on Interactions with Healthcare Professionals, as well as internal company policies and guidelines.

delivering innovative solutions. At the same time we need to improve access to medicines and improved health care. Team-A (The Evolution of Anticoagulation Management-Atrial Fibrillation) is an innovative educational collaboration among ten organizations committed to improving patient outcomes through clinician education. Team-A activities include an array of educational approaches designed from a competency-based framework to meet the needs of healthcare professionals caring for patients with atrial fibrillation needing anticoagulation therapy.

RPC (REMS Program Companies) is comprised of companies that have extended-release (ER) and/or long-acting (LA) opioid products. Please see www.er-la-opioidREMS.com for a listing of the member companies. RPC-supported REMS education is provided through accredited continuing education (CE) activities supported by independent educational grants from these ER/LA opioid analgesics companies.

Teva Women’s Health, Inc. is a division of Teva Pharmaceutical Industries Ltd, headquartered in Israel. The company produces a wide range of women’s healthcare products including oral contraceptives, intrauterine contraception and hormone therapy treatments for menopause and perimenopause. Teva Women’s Health, Inc. maintains a strong commitment to enhancing women’s lives by actively pursuing new areas of research and providing distinct pharmaceutical options that meet women’s needs and fit their lifestyles. Through close engagement with women and healthcare providers, the company maintains an in-depth understanding of the important health matters that affect women.

Sanofi Aventis works to protect the health of the earth’s seven billion inhabitants, improve their quality of life and respond to their potential needs by creating new approaches to our activities and work sectors. Sanofi is mobilized for our priority goal of bringing medicines and vaccines to patients. Through our vaccines and medicines, we help prevent, and where needed, treat those in need. As economies and societies evolve, we need healthy populations to meet the future challenges we will face. Healthcare needs have changed and will continue to do so, and as an industry we have to adapt to meet these needs. To have a real impact, we have to build a sustainable business to invest in

UCB, Inc. was established in 1994, the U.S. affiliate of UCB SA. They have continuously maintained invaluable programs for patients, health care professionals, caregivers and patient communities. Many of the programs they support are noted for their innovation and pioneering work in health care. At UCB their sense of purpose is to help people suffering from severe central nervous system or immunological disorders lead normal, everyday lives. Their ambition is to offer them innovative new medicines and ground-breaking solutions that go beyond the drug. UCB Inc. is committed to enabling cutting-edge scientific research that is driven by the patients’ needs.

Sessions Supporters Releasing the Migraine Vise: Not your Typical Headache Program

Allergan

HIV

Gilead

TEAM-A/Anticoagulation

Bristol-Myers Squibb and Pfizer

Improving Diabetes Outcomes: Placing the Patient at the Center

Novo Nordisk and Sanofi Aventis

General ASA Support

Pfizer

Expand your Practice: Dermoscopy for Family Physicians Workshop

3Gen

Contraception Update and IUD Insertion Workshop

Bayer HealthCare and Teva Pharmaceuticals

Restless Legs Syndrome—Causes, Consequences and Clinical Management

UCB

ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care

ER/LA Opioid Analgesic REMS Program Companies (RPC) via CO*RE (The Collaborative for REMS Education)

Adult Immunizations

NFID and Merck

May 3-5 • San Francisco

2013 Family Physician of the Year

Michelle Quiogue, MD

The California Academy of Family Physicians presents this prestigious award to an individual who exhibits the finest qualities of family physicians and who goes above and beyond in service to patients and community. Dr. Quiogue exemplifies all that is right about family medicine; she is an advocate for her patients, her Academy, her specialty and her community. In her mere 10 years of practice, she has assumed leadership roles in her medical facility, county medical society, the CAFP and the AAFP. Her active engagement in her community ranges from her work in her children’s school to serving as a key contact for her state and national legislators, from spearheading the launch of a mobile health unit to working to save a residency program. In 2012, the family medicine residency program at Kern Medical Center decided not to select a new PGY-1 class of doctors-in-training, citing funding deficits for the reason. Michelle single-handedly rallied interest and spent countless hours campaigning to save the program. Many in her community believe Dr. Quiogue not only saved the program, but also saved many people in the community who would have accessed the emergency room rather than seeing their primary care physician. When Kaiser Permanente invested in a Mobile Health Vehicle to service outlying members in Kern County, Dr. Quiogue was one of the first physicians to volunteer. She has been adamant about making sure that outlying members receive the same continuity of care they receive in Kaiser Permanente facilities. Michelle is also actively engaged in the politics of family medicine, serving as a California Academy of Family Physicians delegate to the CAFP Congress of Delegates and as a key contact to legislators in her local district as well as federal offices. Dr. Quiogue is also a member of the AAFP Commission on Health of the Public and Science. She is currently a member of that commission’s Subcommittee on Health Equity, an Alternate Delegate to U.S. Breastfeeding Committee, and Vice Chair, AIM-HI. In addition to her advocacy roles, she serves on the Board of Directors of her county medical society, and as an alternate delegate to the California Medical Association’s House of Delegates. And finally, Dr. Quiogue is a role model for physicians trying to “have it all.” Dr. Quiogue and her husband, Jason Sperber, made a conscious decision when their first daughter Lucy was born that Jason would remain the at-home parent. Jason is now home with Lucy and daughter #2 Emi. They have been models for others in making this decision, and in the ongoing fight for balance. Dr. Michelle Quiogue is true leader and role model for her peers. She is an active spokesperson for the specialty of family medicine as well as for family physicians’ roles in family, education and public health. Through her involvement with CAFP/AAFP, Michelle has reinvigorated a community of physicians and lit the torch on the future of family medicine. The California Academy of Family Physicians is honored to award Dr. Michelle Quiogue as CAFP’s 2013 Family Physician of the Year.

65th CAFP Annual Scientific Assembly

2013 CAFP Resident of the Year

Raul Ayala, MD

The California Family Medicine Resident of the Year award is given a resident who represents the finest characteristics of family medicine. This year CAFP is honored to give the 2013 award to Raul Ayala, MD, Chief Resident at the University of San FranciscoFresno’s Family Medicine program. Dr. Ayala may have limited free time as a resident, but much of it is spent giving back to others. Dr. Ayala has represented CAFP as co-chair of our Resident and Student Council, at AAFP’s National Conference of Special Constituencies in 2011 and a resident member of the CAFP Board of Directors. He regularly gives back to his own community by working to organize the residency programs in the area and connecting them with their county academy chapters – the Central Valley Alliance project. He

has worked tirelessly on initiating community-wide events and hopes to bring a mobile clinic program to counties in the Central Valley this year. Dr. Ayala holds a Bachelor’s Degree in Science in Biology/Chemistry from the University of Texas, San Antonio and attended the Universidad de Montemorelos, Mexico for medical school. He completed his education through the Fifth Pathway Program at New York Medical College. Dr. Ayala represents everything great about the future of family medicine – he is dedicated to maximizing his impact on patient care through excellent clinical skills, but also through his participation in organized medicine and the political process. Dr. Ayala says he hopes to one day serve a community in need, but we hope he realizes that his energy and enthusiasm is already a beacon of light in his community. Congratulations to 2013 California Family Medicine Resident of the Year Dr. Raul Ayala!

2013 Preceptors of the Year

Alex “Sandy” Sherriffs, MD and Joan Rubinstein, MD This is the inaugural year for this award honoring family physicians who precept and mentor our future generations. In 2013, the CAFP Foundation will celebrate 30 years of our Preceptorship Program. In this program, first-year medical students have the opportunity to spend four weeks of their summer with a practicing family physician in California. It is our pleasure to award the first annual Preceptor of the Year award to two physicians who have been mentoring students since the beginning, Drs. Joan Rubinstein and Alex Sherriffs. For more than 17 years, Drs. Rubinstein and Sherriffs have mentored at least one medical student each summer in their Fowler practice, providing students an opportunity to engage in work in a thriving rural health center. Students experience true full-scope family medicine in Fowler, including flexible sigmoidoscopies, colposcopies, endometrial biopsies, vasectomies and multiple minor surgical procedures. May 3-5 • San Francisco

In addition to their work in Fowler, Drs. Rubinstein and Sherriffs are Clinical Professors in family and community medicine at UCSF Fresno’s Medical Education Program. They are actively involved in their local community, serving on the boards of multiple organizations and cherishing their Fowler community where they raised their two daughters. They are known throughout their community as the town doctors and have been instrumental in supporting community projects, such as raising funds for a community running track. Drs. Rubinstein and Sherriffs, native Californians, met during medical school at the University of California, Davis. They were married during their residency at Valley Medical Center in Fresno. Drs. Rubinstein and Sherriffs have made their mark on many of California’s best and brightest family physicians, with every former preceptee reminiscing about their incredible experience in Fowler. Almost every residency program in family medicine has read at least one essay about time spent in Fowler with the RubinsteinSherriff family and the impact of that fateful summer on their lives as future family physicians. We are honored to present the 2013 Preceptors of the Year award to Drs. Rubinstein and Sherriffs! 17

2013 Award for Educational Excellence in Honor of Barbara Harris

Thomas C. Bent, MD

Tom Bent, MD is a leader in family medicine, an excellent clinician, and a superb teacher. Dr. Bent is Past President of CAFP, has served on the CAFP and AAFP Committees on Professional Development and chaired the AAFP Committee in 2006. Dr. Bent is a founding mentor in the CAFP Continuing Medical Education (CME) Leaders Institute and has mentored many medical students and residents throughout his career. As an educator, Dr. Bent brings his inherent qualities of insight, humor and compassion to bear in a unique and engaging blend. He is able to connect with learners on common ground and with a sense of the “common man” (doctor); he places himself on par with his audience and thus gains their attention, interest and, most importantly, their trust. This stance elicits the audience’s best ability to attend, focus and grasp important educational content. When it comes to medical education, he simply “gets it” and has inspired many young physicians to become active and engaged family doctors. In addition to his teaching, Dr. Bent has delivered care to underserved patients in California for over three decades. Dr. Bent brings a unique, caring perspective to the art of Family Medicine. A staunch and untiring advocate for enhanced access to care for all patients, he is a talented and compassionate clinician. The insight gained from his experience is evident in every aspect of his work, from his sophisti-

cated and accepting worldview to his wry and ready sense of humor. In spite of the many roles he has had, being the personal physician of his patients is likely his favorite accomplishment. Former resident and current member of the CAFP Board of Directors Dr. William Woo recalls Dr. Bent’s passion for education; he took the time to not only discuss each patient’s medical issues, but also found learning points in even the most routine cases. Dr. Bent not only teaches clinical topics with aplomb, but some of the most important lessons former students and residents recall were on building the physician patient relationship. Dr. Bent has forged strong relationships with his patients, many of whom have been seeing him at the community clinic for years. CAFP is proud to recognize his more than two decades of excellence as a family physician educator. Dr. Bent’s contributions are far-reaching, from his clinical care to thousands of patients in many different settings, his leadership expertise to numerous organizations as well as to our specialty, his academic contributions educating countless medical students, residents, and staff physicians from the local to the international level, his research contributions, and of critical importance, his contribution of countless hours and expertise improving the lives of those less fortunate in his community. For these reasons and so many more, CAFP Foundation is proud to honor Dr. Tom Bent as the 2013 Educator of the Year!

2013 “Hero of Family Medicine”

Catherine Sonquist Forest, MD, MPH CAFP developed this award to honor a family physician who has gone above and beyond the call of family medicine and who has ably represented our specialty, our profession and our patients as to be called a true “HERO.” The 2013 award was presented at the Congress of Delegates in March to Catherine Sonquist Forest, MD. Though Dr. Forest is winning this award for 2012-2013, she has been a hero to her patients and to her family physician colleagues for her entire career. Dr. Forest earned her medical degree at UCSF, and completed her family medicine residency at the Community hospital in Santa Rosa, where she was chief resident. She also earned a Master’s depress in public health at University of California Berkeley and completed a public health fellowship at the National Institutes of Health. Since then she has been the epitome of a true family physician champion. 18

She has served for several years on CAFP’s Legislative Affairs Committee, tackling special assignments on health care reform, women’s health, public health, the medical home and reproductive health. She is one of the inaugural CME Leaders Institute fellows, plays a prominent role on the CAFP Ad Hoc committee on Scope of Practice and has represented CAFP at the CMA House of Delegates. Her relentless political advocacy led her to be named April 2012’s FP-PAC Donor of the Month, and within the last few years, she has hosted several events in her home on behalf of FP-PAC for the tenchair of the Assembly Health Committee Bill Monning. She has also been an outstanding key contact, meeting repeatedly with legislators in her District and in the Capitol, advocating for her patients and the issues most important to family physicians. Congratulations to Catherine Sonquist Forest, CAFP’s 2013 Hero of Family Medicine.

65th CAFP Annual Scientific Assembly

Special Recognition On March 3, 2013, the CAFP Congress of Delegates unanimously adopted two resolutions honoring very special CAFP family members: William “Bill Rodgers and Tom Riley. Memorial Resolution | William H. (Bill) RogersAdopted March 3, 2013 by the California Academy of Family Physicians Congress of Delegates Whereas, William H. (Bill) Rogers, Executive Secretary of the California Academy of Family Physicians (initially the California Academy of General Practice) from 1950 to 1982 died peacefully at home on December 16, 2012 in Oakland, California at age 87; and Whereas, Bill Rogers was the Academy’s first executive secretary and was hired away beginning July 1, 1950 from the Alameda County Medical Association where he was employed as bulletin editor and also worked in press relations; and Whereas, Bill Rogers was informed in his letter of hire from then Academy Secretary-Treasurer Francis T. Hodges, MD that it was hoped Mr. Rogers would be “…cognizant of the pioneering nature of your position…and that it represents a challenge to you,” and further “What you make out of yourself and the Academy depends in great amount upon you;” and Whereas, Bill Rogers was to go forward and make a tremendous amount out of himself and the Academy in his 32 years of service; and Whereas, in his farewell message to the members in the January/February 1983 issue of California FP, Bill Rogers’ list of acknowledgements to those with whom he had worked read like a “Who’s Who” of family medicine and general practice; and Whereas, the plaudits accorded to Bill Rogers in that same issue from some of those leading lights of the profession, Sanford Bloom, MD, Hugh Upton, MD and Frank W. Norman, MD, make it clear that Bill Rogers was highly esteemed as a colleague, friend and leader who led quietly and gracefully, provided continuity of thought and action which resulted in the growth and effectiveness of CAFP and ensured its sound fiscal future; and

Whereas, according to further plaudits Bill Rogers received upon his retirement, he “studied us constantly, striving to find ways to improve our efforts in patient care and worked to elevate our public image” and took pride not in the numbers of members making California the largest chapter, but in their excellence; and Whereas, upon his retirement, Bill Rogers enjoyed another 35 years of renovating and operating apartment houses, having built at least three homes early in his marriage to Pat, and was artistic and creative as well as an accomplished photographer; and Whereas, Bill Rogers interrupted his retirement to run the California Academy of Family Physicians on a virtually gratis basis during the illness and eventual death of Barbara Harris, a long-time Academy employee who replaced him as executive secretary when he retired; now, therefore be it RESOLVED: That the California Academy of Family Physicians extends its deepest sympathies and heartfelt thanks to the family of William H. (Bill) Rogers – his wife of 62 years, Patricia Lee (Pat) and four sons Mark (Nancy), Bruce, Paul (Vickie) and Clark (Paige), grandchildren Ryan, Christopher (deceased), Adam (Lily), Brian and Katherine and great grandchildren Logan and Tallulah Rogers, and be it further RESOLVED: That the California Academy of Family Physicians Delegation to the American Academy of Family Physicians (AAFP) submit a memorial resolution for William H. (Bill) Rogers and ask that the AAFP extend its deepest sympathies to the family of William H. (Bill) Rogers. Resolution of Thanks | Tom Riley March 3, 2013 Adopted by the California Academy of Family Physicians Congress of Delegates RESOLVED: The 2013 California Academy of Family Physicians Congress of Delegates hereby recognizes the many years of devoted and exemplary service provided by legislative advocate Tom Riley on behalf of the Academy. He was a thoughtful advocate for family medicine who understood and embraced the values of the Academy and its members and worked tirelessly for the family physicians of California and their patients and the health of all Californians.

Whereas, Bill Rogers was further credited with being able to stimulate others to perform beyond their expectations, a…“great talent to bring out the best in all of us and make us feel we alone were responsible for the effort” while “….working with the most difficult of all material, physicians;” and

May 3-5 • San Francisco

CAFP Foundation We want to thank each and every member who contributed to the Foundation in the past year. We know you had many requests for support, and appreciate the fact that you’ve chosen to remember family medicine in your charitable contributions.

Presidents’ Club Bo Greaves, MD Bob Norman, MD California Family Medicine Program Directors Carol Havens, MD Cynthia Cummings, MD Del Morris, MD and Paula Morris Eric Ramos, MD and Judy Ramos Jay Lee, MD Jimmy Hara, MD Tom Bent, MD and Carolyn Bent

2012-13 CAFP Foundation Donors Alexandra Hunt, MD Abraham Chen, MD Angela Calton, MD Anne M. Zschaechner, MD Anythony Chong, MD Archana Kulkarni, MD Ashby Wolfe, MD Ashley Christiani, MD Barbara and Philip Bos Bernard Katz, MD Beth Grivett Callie Langton, PhD Carla Kakutani, MD Carol Grench, MD Cecile Awayan Cody Mitcheltree Danielle Bascurco David Folsom, MD Del Morris, MD Edward Brantz, MD Edward Sheldon, MD Elisabeth Kalve, MD Emily Ebert, MD

Evan Bass, MD Evelyn Cembrano, MD Farrukh Husain Merchant, MD Francis Chu, MD George Kent, MD Gloria Sanchez, MD Gregory Dahlquist, MD Hector Flores, MD Irina deFischer, MD Jack Chou, MD James Hornstein, MD Jay Lee, MD Jeannine Rodems, MD Jeff Haney, MD Jeff Luther, MD Jeremy Fish, MD Jerri Davis Jessica Mae Bently John Testerman, MD Joseph Shadpour, MD Kelly Jones, MD Kiki Nocella, PhD Kirk Livemont Larry Shore, MD Lauren Simon, MD Leah Newkirk Lee. P Ralph, MD Lenny Fromer, MD Lisa Thomsen, MD Lisa Ward, MD Loretta Stenzel, MD Lucila Tarin, MD Marianne McKennett, MD Mario Leff, MD Mark Dressner, MD Matt Symkowick, MD Maureen Prowse, MD Maureen Strohm, MD Merritt Matthews, MD Michael Panowicz, MD Michael Provenghi, MD Michelle Mertz, MD

Mintek Stosh Monica Quezada, MD Nathan Hitzeman, MD Northridge Family Medicine Pat Davis, MD Pat Moore-Pickett, MD Patricia Samuelson, MD Paulino Schwarz, MD Peter Broderick, MD Pratibha Kumar, MD Ramiro Zuniga, MD Rebecca Bertin, MD Rebecca Jaffe Reynaldo Bayubay, MD Richard Katz, MD Rick Flinders, MD Robert Bourne, MD Robin Lowitz, MD Ron Labuguen, MD Ronald Staib, MD Samantha Malm, MD Scott Nass, MD Shelly Rodrigues Stephanie Le, MD Steve Green, MD Steven Harrison, MD Steven Howard, MD Susan Chiarito, MD Susan Hogeland Susan Hutchinson, MD Susan Saucedo, MD Thomas Badin, MD Tiffany Pierce, MD Tom Badin, MD UC Davis Family Medicine UCLA Family Medicine V Elena Armisen, MD Van La, MD Walt Mills, MD Warren Brandle, MD William Woo, MD Zachary Clopton

2012-13 CAFP Foundation Donations “In Memory of” or “In Honor of”: Tom Bent, MD in Honor of Carol Havens, MD

2012-13 CAFP Foundation Chapter Donors Butte/Glenn/Tehama Academy of Family Physicians Los Angeles County Academy of Family Physicians Orange County Academy of Family Physicians Riverside-San Bernardino Academy of Family Physicians San Luis Obispo County Academy of Family Physicians Yolo County Academy of Family Physicians

2012-13 CAFP Foundation Corporate and Foundation Supporters Believe Health, LLC The Permanente Medical Group, Northern and Southern California Publishing Concepts, Inc. United Way We apologize if we missed your name. Please let us know so we can ensure proper recognition. 65th CAFP Annual Scientific Assembly

Join the Family Physicians Political Action Committee The Voice for Family Medicine in Sacramento Why Support FP-PAC? Contributions to the Family Physicians Political Action Committee (FP-PAC) go directly to candidates who support family medicine and our patients. Your contributions will ensure that the interests of family physicians and our patients are heard amid the deluge of proposals, appeals and requests that besiege candidates every day.

FP-PAC Contributes to Candidates on Both Sides of the Aisle Who Support a Broad Range of Pro-Family Medicine, Pro-Patient issues, including: ✓ Funding for family medicine training ✓ Adequate payment through Medi-Cal and other public programs ✓ MICRA malpractice protections ✓ Fair payment from private third-party payors ✓ Opposing unnecessary physician hassle ✓ Improving access to care Help strengthen family medicine’s voice in California; join the growing number of your colleagues who have already given in 2012 and contribute to FP-PAC today!

FP-PAC Board of Directors Carla Kakutani, MD, Chair Peter Broderick, MD Cynthia Cummings, MD Steven Green, MD

Jimmy Hara, MD Walt Mills, MD Jeannine Rodems, MD Susan Hogeland, CAE, ex-officio

For more information on FP-PAC, please go to www.familydocs.org/fppac.

For more information on FP-PAC, please go to www.familydocs.org/fppac May 3-5 • San Francisco

2013 Contributors In this critically important election year, help strengthen family medicineâ&#x20AC;&#x2122;s voice in California; join your growing number of colleagues who have already given in 2013 and contribute to FP-PAC today!

Capitol Circle ($1,000 to $2,499):

Christina Deckert, MD

Neil Chawla, MD

Cynthia Cummings, MD

Mark Dressner, MD

Jared Garrison-Jakel, MD

Steve Green, MD, FAAFP

Charlene Hauser, MD

Irene Lee, MD

Jimmy Hara, MD, FAAFP

Tae-Woong Im, MD

Joshua Okallo, MD

Carla Kakutani, MD, FAAFP

Veronica Jordan, MD

Daniel Pio, MD

Dana Ware, MD

Elisabeth Kalve, MD

Anjali Rao, MD

Clarissa Kripke, MD

Jason Shen, MD

Platinum ($500 to $999): Irina deFischer, MD Jay Lee, MD, MPH Del Morris, MD Jeannine Rodems, MD, FAAFP

Gold ($250 to $499): David Bazzo, MD, FAAFP Anthony Chong, MD Jeremy Fish, MD Catherine Sonquist Forest, MD, MPH Carol Havens, MD, FAAFP James T. Hay, MD, FAAFP Susan Hogeland, CAE Joseph Leonard, MD Teresa Naverez, MD Lee Ralph, MD Elizabeth Renner, MD Lisa Ward, MD William Woo, MD

Hobart Lee, MD Sharon Lin, DO Panna Lossy, MD Jeffrey Luther, MD, FAAFP Sofia Meraz, MD Pat Moore-Pickett, MD Leah Newkirk Arthur Ohannessian, MD Joe Provenzano, DO Maisara Rahman, MD Carlos Ramirez, MD Al Ray, MD Shelly Rodrigues, CAE, CCMEP Kevin J. Rossi, MD Pat Samuelson, MD, FAAFP Susan Saucedo, MD Tara Scott, MD Larry Shore, MD

Patrick Yassini, MD

Lauren M. Simon, MD, FAAFP

Silver ($99 to $249):

Norma Jo Waxman, MD

Odilia Anthony, MD Raul Ayala, MD Evan Bass, MD Daniel B. Castro, MD, FAAFP

Ronald H. Labuguen, MD

Vicky Valverde-Salas, MD Ashby Wolfe, MD, MPP, MPH

Student and Resident Platinum ($50):

Student and Resident Gold ($25): Mark Ard Cono Badalamenti, MD Cathryn Christensen, MD Laura Doan Edwin Kwon, MD Michael Lee Talha Memon, MD Megan Oakes Sunny Pak, MD Peter Reding, MD Diana Sephri Harvey, DO David Tran Matthew Varallo

General Donations (up to $99): Suzan Goodman, MD, MPH Sophia Henry Carl Knopke, MD Cody Mitcheltree Joan Rubinstein, MD Alex Sherriffs, MD Elise Singer, MD Karen Sproull Jackson, MD Eryn Xavier, MD

Rebecca Bertin, MD

65th CAFP Annual Scientific Assembly

CAFP congratulates all of its members celebrating their 30-40-50 and even 60-year membership anniversaries with the Academy. CAFP thanks each of you for your support and contributions to our efforts to champion family medicine and serve California family physicians. We look forward to continuing to work together for many years to come! With your continued support, we have: • Strengthened the voice of family physicians throughout the state • Increased the number of professional development programs we provide to all members • Positioned family physicians as uniquely qualified patient advocates on a multitude of policy issues Thank you for your contributions to our efforts to champion family medicine and serve California family physicians.

Congratulations to the 103 CAFP members who are celebrating 30 years with the Academy this year: Jose A. Alegre MD, FAAFP James M. Amberg, MD, FAAFP Navinchandra M. Amin, MD, FAAFP Stephen G. Axelrode, DO, FAAFP Robert H. Barron, MD Eric R. Batres, MD, FAAFP Martin Bennett, MD Frederick P. Benson, MD Deborah J.M. Biller, MD Nancy A. Bleile, MD, FAAFP Daniel D. Blodgett, MD Richard Boucher, MD, FAAFP Jennifer A. Burnett, MD, MS, FAAFP Douglas C. Cambier, MD, FAAFP Vicente L. Carbonell, MD Eing-min Chang, MD, FAAFP Lynne M. Coen, MD Jorge V. Contreras, MD Randy E. Coriell, MD Jack L. Cox, MD, FAAFP Thomas W. Cummings, MD, FAAFP Paul F. DeChant, MD, MBA, CEO, FAAFP James Dewell, MD, FAAFP Lynne Diamond, MD William K. Ebert, MD Brien E. Ecker, MD Bill W. Eng, MD, FAAFP Arnold Epel, MD, FAAFP Mary E. Ferris, MD, FAAFP Gary M. Flashner, MD Alan N. Fleckner, MD, FAAFP Fred J. Galluccio, MD, FAAFP Kirk S. Gilbert, MD Theodore J. Hak, MD, FAAFP May 3-5 • San Francisco

Mattice F. Harris Jr., MD, FAAFP Lynn E. Hawley, MD, FAAFP Laurie S. Hedden, MD Donna M. Hickox, MD Daniel Honigman, MD, FAAFP James S. Hornstein, MD, FAAFP John W. Hunter, MD Siroos Ighani, MD, FAAFP Jacqueline Jayne, MD, FAAFP Clifford R. Jones, MD, FAAFP Paula M. Joubert Greene, MD, FAAFP Harpal S. Kainth, MD, FAAFP George P. Kent, MD Lee G. Kissel, MD, FAAFP J. Michael Lee, MD, FAAFP Vincent Chi-wing Lo, MD, FAAFP Danny Lock, MD, FAAFP Geoffrey L. Loman, MD John B. Luster, MD Wai-Man T Ma, MD Thomas S. McBreen, MD, FAAFP Margaret E. McCahill, MD, FAAFP Walter W. Mills, MD Gabriel G. Miranda, MD, FAAFP James P. Murray, MD, FAAFP Thomas Nesbitt, MD, MPH, FAAFP Douglas Nitta, MD, FAAFP Edmond C. Noll, MD, FAAFP Robert M. Norman, MD Donna L. Norquist, MD Maria C. Ortiz, MD, FAAFP David R. Paskil, MD, FAAFP Jared A. Paskin, MD, FAAFP Carey B. Paul, MD Robert G. Peterson, MD, FAAFP

Karen M. Philippi, MD Michael Pin, MD Pasquale R. Pingitore, MD Francisco J. Prieto, MD Timothy J. Regan, MD David B. Rollins, MD, FAAFP Timothy S. Schmidt, MD, FAAFP Mark Sendar, MD Michael J. Shaw, MD, FAAFP Ronald K. Shimmin, MD, FAAFP Joseph L. Smith, MD, FAAFP Larry Snyder, MD Alvin M. Sockolov, MD Heidi Solz, MD Barbara W. Stewart, MD, FAAFP Germaine Strother, MD, FAAFP Donna M. Sund, DO Joanna Kit-Ying Tan, MD, FAAFP Kenneth K. Tan, MD, FAAFP Patrick S. Thompson, MD, FAAFP Hamid A. Towhidian, MD Suong My Tuong, MD, FAAFP Richard B. Turner, MD John M. Turner, MD, FAAFP Jeffrey Unger, MD, FAAFP Steven J. Vilter, MD, FAAFP Hilliard S. Webb, MD Arnold Welden, MD Christopher N. White, MD Catherine A. Wille, MD Kevin Wingert, MD, FAAFP Thomas L. Wisler, MD Ronald A. Zent, MD, FAAFP Ross E. Ziegler, MD, FAAFP

Congratulations to the 52 CAFP members who are celebrating 40 years with the Academy this year: Angel Alpas, MD, FAAFP Stanley I. Arbiter, MD, FAAFP Eugene Arellano, MD, FAAFP Raymond A. Bessemer, MD, FAAFP Werner R. Bierfreund, MD, FAAFP Welby W. Bigelow Jr., MD Wayne O. Buck, MD, FAAFP Hugh W. Burrell, MD Dewayne E. Caviness, MD, FAAFP Neville O. Chan, MD, FAAFP Joseph G. Clendenin, MD, FAAFP Melvin S. Cohen, MD, FAAFP Harold L. Cowan, MD, FAAFP Wallace L. Cowdell, MD, FAAFP John V. Dervin, MD William A. Fitzpatrick, MD, FAAFP Lawrence D. Freedman, MD, FAAFP Myron Gananian, MD

Gloria P. Gay, MD, FAAFP William Z. Good, MD, FAAFP Iona F. Hammond, MD, FAAFP Paul Z. Han, MD, FAAFP Ralph H. Harder, MD Roger V. Hendrickson, MD Douglas C. Hill, MD Doyle E. Johnson, MD, FAAFP Caesar O. Julian, MD, FAAFP Charles E. Keenan Jr., MD, FAAFP Cynthia A. Lacy, MD Donald J. Lantz, MD, FAAFP Ben R. Leonard, MD, FAAFP Barnet G. Meltzer, MD David S. Mizes, MD Glenn M. Moss, MD, FAAFP Otto W. Neubuerger, MD, FAAFP Arthur M. Owens, MD, FAAFP

David T. Perlmutter, MD Nicholas Poulos, MD, FAAFP J.V. Rasinski Jr., MD Reginald D. Rice, MD, FAAFP Eugene Rogolsky, MD, FAAFP Sam J.W. Romeo, MD, FAAFP Marianne Tahl, MD, FAAFP William T. Royal, MD, FAAFP Joseph C. Rudison, MD, FAAFP Ronald B. Rushford, MD, FAAFP John R. Schafer, MD, FAAFP William B. Shore, MD, FAAFP Stephen D. Smith, MD William S. Weil, MD, FAAFP Leon Wesner, MD, FAAFP Jeff T. Wilkes II, MD

Congratulations to the five CAFP members who are celebrating 50 years with the Academy this year: Charles B. French, MD, FAAFP James E. Chargin, MD

Wesley J. Masterjohn, MD, FAAFP John G. Pace, MD, FAAFP

Benjamin D. Parmeter, MD

Congratulations to the four CAFP members who are celebrating 60 years with the Academy this year: Walter F. Korcek, MD, FAAFP Wendell E. Brown, MD, FAAFP

Herbert E. Fisher, MD, FAAFP George S. Haas, MD, FAAFP

65th CAFP Annual Scientific Assembly

CME Scorecard Please use this scorecard to keep track of the sessions you’ve attended at this meeting. It will be a helpful reminder to you as you file your CME report with AAFP. Questions? Ask any CAFP staffer.

Session

Attended

Credits

IUD Insertion

Yes

2.5

Dermascopy

Yes

2.5

SAMS: Maternity Care

Yes

SAMS: Pain Management

Yes

Migraines: Leung and Sonquist-Forest

Yes

Dementia: Flores

Yes

.75

Lunch and Learn: Opioid/REMS: Bazzo and Havens

Yes

1.5

HIV: Kubota

Yes

HEP C: Kent

Yes

TBI/Head Injuries: Ralph

Yes

Obesity in Kids: Simon

Yes

Autism: Schneider

Yes

TEAM-A/Stroke: Dressner

Yes

All Member “Two Slides”

Yes

1.5

Notes

Friday, May 3

Saturday, May 4

May 3-5 • San Francisco

Session

Attended

Credits

Opening Session

Yes

Immunizations: Joseph and Hogue

Yes

Diabetes: Greaves and Sadler

Yes

Cancer Screening: Woo

Yes

.75

Notes

Sunday, May 5

Restless Leg: Doghramji and Doghramji

ICD-10 Seminar

2.0

Reporting your CME is Easy: www.aafp.org Fast, efficient and you have control!

65th CAFP Annual Scientific Assembly

Past Presidents Ivan C. Heron, MD

1949

Harrison McCandless, MD

1984

Fredrick Ewens, MD

1950

Richard C. Barnett, MD

1985

David F. Dozier, MD

1951

Sam W. Smith, MD

1986

L.C. Burwell, MD

1952

Richard Katz, MD

1987

Francis T. Hodges, MD

1953

Merlin H. Mauk, MD

1988

Merlin L. Newkirk, MD

1954

Eugene Felmar, MD

1989

John G. Walsh, MD

1955

Robert Pedrin, MD

1990

1956

Harry W. Depew, MD

1991

1992

Charles A. Preuss, MD

Joseph W. Telford, MD

1957

Mary Frank, MD

A.J. Franzi, MD

1958

Gregory Dunford, MD

1993

Carroll B. Andrews, MD

1959

Mattice Harris, Jr., MD

1994

Leon A. Desimone, MD

1960

Joseph E. Scherger, MD, MPH 1995

Clarence T. Halburg, MD

1961

Stephen Brunton, MD

1996

Burt L. Davis, MD

1962

Paulette J. Adams, MD

1997

John A.C. Leland, MD

1963

Norman Rosen, MD

1998

Ralph L. Bennett, MD

1964

Robert Bourne, MD

1999

Horace F. Sharrocks, MD

1965

Barbara Kostick, MD

2000

J. Blair Pace, MD

1966

Leonard Fromer, MD

2001

2002

Herbert A. Holden, MD

1967

Richard Zachrich, MD

Dudley M. Cobb, MD

1968

Emily Ebert, MD

2003

Frank W. Norman, MD

1969

Dana Ware, MD

2004

Edward H. Platz, MD

1970

Eric Ramos, MD

2005

Benson R. McGann, MD

1971

Bo Greaves, MD

2006

Thomas Stern, MD

1972

Carla Kakutani, MD

2007

Ransom Turner, MD

1973

Jeffrey Luther, MD

2008

Robert D. McGinnis, MD

1974

Thomas Bent, MD

2009

Edwin Reithmayer, MD

1975

Jack Chou, MD

Holger Rasmussen, MD

1976

Carol Havens, MD

2011

Nicholas P. Krikes, MD

1977

Steven Green, MD

2012

Wilfred Snodgrass, MD

1978

Simon Brumbaugh, MD

1979

Hugh M. Upton, MD

1980

John P. Crivaro, MD

1981

John Francis Quinn, MD Robert F. Tomfohrde, MD

May 3-5 â&#x20AC;˘ San Francisco

1982

2010

CAFP would like to welcome Mark Dressner, MD to his position as 2013-14 President. He joins a very distinguished list of fine family physicians and we know he will do an excellent job representing family medicine.

1983

Board of Directors and Staff Directory CAFP Foundation

Officers Mark Dressner, MD, MEd Del Morris, MD Steve Green, MD Jay W. Lee, MD, MPH Lee Ralph, MD Lisa Ward, MD

President President-Elect Immediate Past President Speaker Vice Speaker Secretary/ Treasurer

District Directors Taejoon Ahn, MD, MPH Evan Bass, MD David Bazzo, MD Raul Ayala and Irene Lee-Klass, MD (Resident Directors) Irina deFischer, MD Elizabeth Kalve, MD Tae-Woong Im, MD Veronica Jordan, MD (Rural Director) Edwin Kwon and Matthew Abinante (Student Directors) Walter Mills, MD Patricia Moore-Pickett, MD Joan Rubinstein, MD Jeannine Rodems, MD Lisa Ward, MD (New Physician Director)

Editor, California Family Physician

Jimmy H. Hara, MD, President Callie Langton, PhD, Executive Director

Staff

Susan Hogeland, CAE Executive Vice President Shelly Rodrigues, CAE, CCMEP, FACEHP Deputy Executive Vice President Allison Bauer Manager, Communications and Website Jane Cho Manager, Medical Practice Affairs Jerri Davis, CCMEP Senior Manager, CME/CPD Adam Francis Deputy Director, Government Relations and PAC Coordinator Kelly Goodpaster Manager, Finances and Accounting Sophia Henry Associate Director, Membership and Marketing Callie Langton, PhD Director, Health Workforce Policy Cynthia Kear, MDiv, CCMEP Senior Vice President Cody Mitcheltree Coordinator, Student and Resident Affairs and Social Media Leah Newkirk, JD Director, Health Care Policy

Michelle Quiogue, MD

AAFP Delegates Jack Chou, MD Carla Kakutani, MD

AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD

65th CAFP Annual Scientific Assembly

Schedule for Friday, May 3 _____________________________________

F Workshop: Contraception Update and 30 R IUD Insertion Training (Madison Carmichael) I Norma Jo Waxman, MD D Workshop: Expand Your Practice: 31 Dermoscopy for Family Physicians A Michael Van Buskirk, MD Y SAMS: Maternity Care 32

1:00-3:30 pm 1:00-3:30 pm 1:00-5:00 pm 1:00-5:00 pm

May 3-5 â&#x20AC;˘ San Francisco

Page

Tipu Khan, MD

SAMS: Pain Management Lauren Simon, MD

Hand-On Procedural Workshops

Friday, May 3, 2013 | 1:00-3:30 pm

IUD Insertion

Norma Jo Waxman, MD

Activity Description Participants will begin with a didactic session on reproductive options and then complete a hands-on session for IUD insertion. Models will be used for practice. Learning Objectives At the end of the educational activity participants should able to: - List current, evidence based selection criteria for appropriate IUD candidates. - Develop skills required for safe insertion of IUDs, and be able to address pain management. - Evaluate and treat both common and concerning IUD complications. Norma Jo Waxman, MD is in private practice in San Francisco, affiliated with Brown & Toland Physicians. She has been active nationally in efforts to provide comprehensive contraception insurance coverage, prevent restriction to abortion access, and the move to expand “opt-out” abortion training in family medicine residencies. She speaks nationally to health care providers on issues involving Reproductive and Women’s Health, Adolescent Medicine and Primary Care. Her passion is educating providers and the public about effective contraception, especially intrauterine contraception. Dr. Waxman is active in professional organizations including the American Medical Women’s Association, where she is the Advocacy Committee co-Chair, the Association of Reproductive Health Professionals, where she is a member of clinical expert panels on Women and Depression and Women and Migraines, and the California Academy of Family Physicians (CAFP), who she represents at the California Coalition for Reproductive Freedom. Dr. Waxman graduated with a B.S. from UC Berkeley, completed medical school at St. Louis University, and completed her Family Medicine Residency at UCSF/SFGH in 1991. Faculty Disclosure: Dr. Waxman declares that in the past 12 months neither she, nor any member of her immediate family, has had a relevant financial interest in corporate entities supporting this meeting. She is on the Scientific Advisory Board of Medicine 360, a not-for-profit organization. The handouts for this session will be provided at the session. This activity is supported by unrestricted educational grants from TEVA and Bayer Pharmaceuticals.

65th CAFP Annual Scientific Assembly

Hand-On Procedural Workshops

Friday, May 3, 2013 | 1:00-3:30 pm

Expand your Practice: Dermascopy for Family Physicians

Michael Van Buskirk, MD

Activity Description This hands-on session is a follow-up to last yearâ&#x20AC;&#x2122;s highly rated lecture on dermascopy. Participants will get an opportunity to dive deeper into the procedure and have time to try out a scope. Learning Objectives At the end of the educational activity participants should able to: - Define the skin conditions where dermascopy is a preferred treatment option - Perform a successful dermascope procedure in a practice setting

F R I D A Y

Board certified in family medicine, Dr. Van Buskirk has been recognized for his work in complex internal medicine. He has provided exceptional health care for North County families since 1982. He joined the Scripps Clinical Medical Group in 1993 and is a voluntary clinical professor at UCSD in the Department of Family and Preventative Medicine. Dr. Van Buskirk received his medical education at the Autonomous University of Guadalajara, Mexico and the University of Southern California. He completed his internship and residency at the USC/Los Angeles County Medical Center and the USC/Whittier Presbyterian Intercommunity Hospital. A husband and father of six, he is fluent in English and Spanish and teaches Sunday school at his church. His hobbies include golf, martial arts and fly-fishing. Faculty Disclosure: Dr. Van Buskirk declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. The handouts for this session will be provided at the session. This activity is supported by an unrestricted educational grant from 3Gen.

May 3-5 â&#x20AC;˘ San Francisco

American Board of Family Medicine

Self-Assessment Modules

Friday, May 3, 2013 | 1:00-5:00 pm Maternity Care Tipu Khan, MD

Activity Description This interactive session will take learners through the 60 SAMs questions with discussion of the correct answers and references. At the end of the session, all attendees will be submitted to ABFP for completion of Stage 1 of the SAMS. Learning Objectives At the end of the educational activity participants should able to: - Define standards of care in maternity care - Identify risk factors and presentations in high risk patients - Incorporate PCMH tenets into mother, child and family care in practice Tipu V. Khan, MD, is a family physician at California Hospital Medical Center (CHMC) in Downtown Los Angeles, an urban underserved community hospital. Dr. Khan practices full spectrum family medicine including full obstetrics care, from vaginal deliveries to cesarean sections. CHMC is a unique institution in that family physicians who have completed a surgical obstetrics fellowship may seek privileging for medical, non-operative, and operative obstetrics. He is faculty at the University of Southern Californiaâ&#x20AC;&#x2122;s Keck School of Medicine, Department of Family Medicine. Dr. Khan is a member of the first class of the CAFP CME Leaders Institute and the CAFPâ&#x20AC;&#x2122;s Committee on Continuing Professional Development. Faculty Disclosure: Dr. Khan declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. The handouts for this session will be provided at the session.

65th CAFP Annual Scientific Assembly

American Board of Family Medicine

Self-Assessment Modules

Friday, May 3, 2013 | 1:00-5:00 pm

Pain Management Lauren Simon, MD, MPH

F R I D A Y

Dr. Simon graduated from Hahnemann University School of Medicine in Philadelphia, Pennsylvania in 1990. She completed a primary care sports medicine fellowship at Kaiser Permanente in Fontana in 1994. Dr. Simon received a master of public health degree at Loma Linda University School of Public Health in 1994. She is board certified with the American Board of Family Medicine, with an added certificate in sports medicine. Dr. Simon was employed with Kaiser Permanente during her sports medicine fellowship and in our extended care department until she joined our group in July of 1994. She is an assistant professor at Loma Linda University School of Medicine. She serves as team physician for University of California, Riverside; University of Redlands, and Redlands High School. Dr. Simon provides a broad spectrum of services within her expertise. In addition to providing family care she has special emphasis in sports medicine, obstetrics, and adolescent medicine. You may even find her on the sidelines at your local sporting events. Her vivacious personality and energetic nature attracts patients of all ages. She is committed to providing comprehensive health care for all members of your family. Dr. Simon is a member of the first class of the CAFP CME Leaders Institute and the Cahir of CAFPâ&#x20AC;&#x2122;s Medical Student and Resident Affairs Committee. Faculty Disclosure: Dr. Simon declares that in the past 12 months neither she, nor any member of her immediate family, has had a relevant financial interest in corporate entities supporting this meeting. The handouts for this session will be provided at the session.

May 3-5 â&#x20AC;˘ San Francisco

Schedule for Saturday, May 4 2013 _____________________________________ Page 8:00-8:30 am

Opening Remarks and Welcome David Bazzo, MD

8:30-9:30am Keynote: Setting the Stage for the Family of Family Medicine 35 Reid Blackwelder, MD AAFP President-Elect 9:45-10:45 am Releasing the Migraine Vise: 36 Not your Typical Headache Program (Camille Carmichael) Geoffrey Leung, MD and Catherine Sonquist Forest, MD

10:45-11:30 am

Pondering, Wandering and other Dementia Dilemmas 49 (Ted and Esther Young) Chris Flores, MD

12:00-1:30 pm

Opioid REMS: Achieving Safe Use 66 While Improving Patient Care David Bazzo, MD and Carol Havens, MD

2:00-2:30 pm

HIV Prevention and Screening 108 (Mark Carmichael) Marshall Kubota, MD

2:30-3:00 pm

Hep C: Asking the Right Questions 120 (Chris Lee) George Kent, MD

3:00-3:30 pm

Tips for TBI Screening 123 (Anthony Jones) Lee Ralph, MD

4:00-4:30 pm

Busting Autism Myths 139 (Conner and Ethan Carmichael-Perez) David Schneider, MD

4:30-5:00 pm

Weight Issues for Kids 165 (Jenae and Sean Jones) Lauren Simon, MD

5:00-5:30 pm Best Practices for Secondary Stroke Prevention 183 (Kwan Lee) Mark Dressner, MD 65th CAFP Annual Scientific Assembly

Session 1: Saturday, May 4, 2013 | 8:30-9:30 am

Keynote Address: Keeping the Family in Family Medicine: Meet the Carmichaels

Reid Blackwelder, MD President-Elect, American Academy of Family Physicians Learning Objectives At the end of the educational activity participants should able to: - Discuss the Carmichael family members in the context of the PCMH and family medicine practice - Use the Carmichael family as a basis of table conversation and case problem solving. - Compare the Carmichael family members to your own practice and identify intentions to change for your patient care. Reid B. Blackwelder, MD, FAAFP, a family physician in Kingsport, Tenn., is president-elect of the American Academy of Family Physicians. Previously, he served three years as a member of the AAFP Board of Directors. Outside the AAFP, he serves as director of the Medical Student Education Division for the Department of Family Medicine at East Tennessee State University’s James H. Quillen College of Medicine in Johnson City, Tenn., where he is also a professor of family medicine. He previously served as program director of the Kingsport Family Medicine Residency Program of ETSU for more than 13 years and Dr. Blackwelder remains on faculty at the residency. A member of the AAFP since 1980, Dr. Blackwelder has served on and chaired numerous committees and commissions whose work has focused on continuing professional development and education. He also was a delegate to the AAFP Congress of Delegates. In 2008, the AAFP awarded Dr. Blackwelder its Exemplary Teacher of the Year Award. A member of the Tennessee Academy of Family Physicians since 1992, Dr. Blackwelder served in several positions, including president. He has been a member of the board of directors for more than 10 years and has served in multiple capacities on numerous TNAFP committees. He represented the chapter at the AAFP Congress of Delegates beginning in 2002, until his election to the AAFP Board of Directors. In 2008, the TNAFP awarded Dr. Blackwelder its prestigious John S. Derryberry Distinguished Service Award.

S A T U R D A Y

In addition to caring for patients and serving in leadership roles for the AAFP, Dr. Blackwelder has dedicated a significant amount of his time to teaching medical students and residents. In fact, his dedication has earned him a plethora of outstanding teaching awards, including several awards from his local Caduceus Club, the Humanism in Medicine Award from the New Jersey Health Foundation and the Dean’s Teaching Award from ETSU. Dr. Blackwelder earned his undergraduate degree in biology from Haverford College in Haverford, Pa., and his medical degree from Emory University in Atlanta, graduating cum laude and as a member of Alpha Omega Alpha Medical Honor Society. He then completed his residency at the Medical College of Georgia in Augusta serving as chief resident. He is board certified by the American Board of Family Medicine and has the AAFP Degree of Fellow, an earned degree awarded to family physicians for distinguished service and continuing medical education. Faculty Disclosure: Dr. Blackwelder declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

May 3-5 • San Francisco

Session 2: Saturday, April 21 | 10:00-11:00 am

Releasing the Migraine Vise: Not Your Typical Headache Program (Camille Carmichael)

Geoffrey Leung, MD and Catherine Sonquist Forest, MD

Learning Objectives At the end of this educational activity participants should be able to: - Demonstrate an understanding of the under-diagnosis of migraine - Use evidence based tools to screen for migraine - Integrate current evidenced-based treatment guidelines for acute and preventive migraine into your clinical practice Geoffrey Leung, MD, former Chair of CAFP’s Committee on Continuing Professional Development is back! Geoffrey Leung, MD, EdM has joined the Family Medicine department at Bellevue Medical Center. Dr. Leung comes to us from Riverside County Regional Medical Center where he served as the Associate Program Director for the Family Medicine Residency Program. He also worked as a Clinical Assistant Professor of Family Medicine at Western University of Health Sciences. Dr. Leung earned his medical degree at Baylor College of Medicine. He then completed his family medicine residency at Kaiser Orange County where he served as the Chief Resident in his final year. Additionally, he has a Master of Education from Harvard Graduate School of Education. Dr. Leung is board certified in Family Medicine. Catherine Sonquist-Forest is a board-certified family medicine specialist at the UCSF Family Medicine Center at Lakeshore. Dr. Forest cares for patients of all ages but is particularly interested in pediatrics and adolescent medicine, women’s health, LGBT health, transgender primary care, sports medicine, and the coordination of hospice and end-of-life care. She’s also has expertise in integrative health and occupational health. Dr. Forest earned a medical degree at UCSF and completed a residency in family medicine at the Community Hospital of Santa Rosa, where she was chief resident. She also earned a master’s degree in public health at the University of California at Berkeley and, as part of that program, completed a public health fellowship funded by the National Institutes of Health. She is a member of the CAFP’s Legislative Affairs Committee and was awarded the CAFP’s 2013 Hero of Family Medicine Award for her role in advocacy. Faculty Disclosure: Drs. Leung and Sonquist-Forest declare that in the past 12 months neither they, nor any members of their immediate families, have had a relevant financial interest in corporate entities supporting this meeting. This activity is supported by an unrestricted educational grant from Allergen.

65th CAFP Annual Scientific Assembly

4/3/2013

This program is supported with an unrestricted educational grant from Allergan 2013| California Academy of Family Physicians

S A T U R D A Y

Today’s Faculty Catherine Sonquist Forest, MD, MPH Clinical Instructor UCSF Medical Center at Lakeshore San Francisco, CA Geoffrey Leung, MD, EdM Chief of Family Medicine Riverside County Health System Riverside, CA

Disclosures • The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP. • It is the policy of CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all of their continuing education activities. • Drs. Forest and Leung have nothing to disclose.

May 3-5 • San Francisco

4/3/2013

Learning Objectives • Demonstrate an understanding of the under-diagnosis of migraine • Use evidence based tools to screen for migraine • Integrate current evidenced-based treatment guidelines for acute and preventive migraine into your clinical practice

ScreenMigraine • Online migraine community for you facilitated by us • Private! Secure! • Interact, share, learn Sign up by accepting your email invitation or email: ScreenMigraine@familydocs.org

ScreenMigraine • Why Yammer? • What will we do? • How will this help me?

65th CAFP Annual Scientific Assembly

4/3/2013

The Diagnosis is missed in what percent of Patients presenting to Primary Care with Headache and meeting the criteria for migraine? 0% 0% 0% 0%

1. 2. 3. 4.

10 percent 15 percent 25 percent 50 percent

•

56 year-old female

•

Active runner

•

High pressure job

•

Insomnia

•

Headache

S A T U R D A Y

• EVERY new patient intake • ANY contraceptive change • EACH mention of headache

May 3-5 • San Francisco

4/3/2013

Screening It only takes 3 simple questions….

ID Migraine™ Validated Screener During the last 3 months, did you have the following with your headaches: 1.

You felt nauseated or sick to your stomach Yes ___ No ___

Light bothered you (a lot more than when you don’t have headaches) Yes ___ No ___

Your headaches limited your ability to work, study, or do what you needed to do? Yes ___ No ___

•2/3 for migraine: •Sensitivity:0.81 •Specificity: 0.75

Lipton et al. Neurology 2003;61:375-382 ID Migraine is a trademark of Pfizer Inc.

Which of the following pieces of information would be revealed by the ID Migraine ™ Validated Screener? 1. Patient had 5 headache episodes, lasting 4-72 hours 0% 2. Patient’s headache is worsened by movement 3. Patient’s headaches have limited her ability to 0% do what she need to do 0% 4. Patient’s headache is unilateral and throbbing 0%

65th CAFP Annual Scientific Assembly

4/3/2013

• 56 yo female • Active runner • High pressure job • Insomnia

• Current headaches • • • • •

Preceded by sinus congestion Throbbing Worse with movement Missing work Has had headaches like this on and off her whole life

S A T U R D A Y

Worrisome Headache Red Flags: ‘SNOOP’ When in doubt, investigate the atypical!

Systemic symptoms Secondary risk factors Neurologic symptoms Onset Older Pattern change Previous headache history Sadovsky D, Dodick DW. Am J Med 2005: 118, Suppl 1, 11S-17S.

Int’l Classification of Headache Disorders (ICHD-II/ IHS) Criteria for Migraine w/o Aura Migraine is Episodic Headache, ≥ 5 episodes, lasting 4-72 hrs with:

Any 2 of: • unilateral • throbbing + • worsened by movement • moderate or severe Headache Classification Subcommittee of the International Headache Society. Cephalalgia. 2004;24 (suppl 1):1–160.

Any 1 of: • nausea or vomiting • photophobia and phonophobia

No secondary cause

2+1 = Migraine

May 3-5 • San Francisco

4/3/2013

4 Stages of Migraine • PRODROME - irritability

▫ 40 - 60% experience ▫ Duration: A few hours to a few days

• AURA – sparking lights

▫ 20% experience ▫ Duration: 20 to 60 minutes

 (>1 hr can be risk of migraine-related stroke)

• HEADACHE - throbbing ▫ nearly 100% experience ▫ Duration: 4 to 72 hours

• POSTDROME (migraine hangover) - fatigue ▫ 70% Experience ▫ Duration: A few hours to a few days

• Headache Contributors ▫ ▫ ▫ ▫ ▫ ▫ ▫

Too little sleep Work stress Travel Missed meals Alcohol Long workouts/dehydration Loud environments

• 56 yo female • Active runner • High pressure job • Insomnia

Migraine Contributors (non exhaustive) • Sleep (too much/too little/ • Hormonal changes irregular)

• Low blood sugar/skipping meals • Stress/tension • Alcohol (esp. red wine) • Dehydration • Certain foods (highly

~menses/pregnancy/meno pause • Exercise (complex – regular also helps)

individual)

65th CAFP Annual Scientific Assembly

4/3/2013

Migraine Contributors (cont.) • Sensory overload ~ Lights – flashing, fluorescent ~ Sounds – loud, piercing ~ Smells – perfumes, pungent, cleaning fluids

• Smoke • Caffeine (complex - also

humidity)

• • • •

Dust exposure Sex (also can help) Trauma TMJ, bruxism, or other dental problems

used to treat)

• Weather changes (low

pressure zones, changes in

• Self-Treatment ▫ Acetaminophen ▫ Ibuprofen ▫ Lie still in a quiet room

S A T U R D A Y

• 56 yo female • Active runner • High pressure job • Insomnia

• Acetaminophen • NSAIDS (ibuprofen, ketorolac, etc.) • Ergotamines / dihydroergotamines • Anti-emetics • Steroids • Magnesium • Triptans

May 3-5 • San Francisco

4/3/2013

Triptans Three (3) F’s: Fast versus slow, Formulation, Formulary Group 2 – slower Group 1 – faster onset and longer onset half-life • Sumatriptan • Naratriptan • Zolmitriptan • Frovatriptan • Rizatriptan • Almotriptan Rapoport et al. CNS Drugs 2003;17:431-447 • Eletriptan Tepper SJ. Neurology Continuum 2006;12:87-105

• Pain free within 2 hours • Headache diary shows still having 2 migraines a week ▫ Desires fewer migraines

• 56 yo female • Active runner • High pressure job • Insomnia

• Candidate for daily prevention?

Success outcome: Migraine-ACT • Impact at 2 hours • Relief at 2 hours • Consistency of response • Daily planning • A Migraine-ACT score of ≤ 2 suggests a need to switch acute medications

Dowson AJ et al. Current Medical Research and Opinion 2004;20:1125-1135 Tepper SJ et al. Headache Care 2005;2:27-31

65th CAFP Annual Scientific Assembly

4/3/2013

When to consider daily prevention • • • • • • •

Pattern of increasing attacks Patient preference Pregnancy Severe disabling attacks Interference with daily routine Side-effects from acute medications Special circumstances: ▫ Hemiplegic migraine ▫ Risk of permanent neurological injury

Silberstein SD & Goadsby PJ. Cephalalgia 2002;22:491–512. Silberstein SD. Migraine and pregnancy. Neurologic Clinics 1997; 15:209–31 Ramadan NM, et al. Evidenced-based guidelines … for prevention of migraine.www.neurology.org,2000

S A T U R D A Y

Which of the following therapies do NOT have level A evidence for prevention of episodic migraine? 0% 0% 0% 0% 0%

1. 2. 3. 4. 5.

Metoprolol Topiramate Verapamil Petasites None, all level A evidence

2012 AHS/AAN Guidelines for Prevention of Episodic Migraine • Level A: Metoprolol, Propranolol, Timolol, Topiramate, Divalproex/sodium valproate, Petasites (butterbur) • Level B: Amitriptyline, Feverfew, Magnesium, Venlafaxine, Atenolol • Level C: Lisinopril, Coenzyme Q-10, Cyproheptadine • Level U: Gabapentin, Verapamil, Fluoxetine • To date only OnabotulinumtoxinA is indicated for chronic migraine Loder, E et al. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison with other Recent Clinical Practice Guidelines Headache 2012;52:930-945

May 3-5 • San Francisco

4/3/2013

Supplements-Evidence • Magnesium (600 mg daily) Level B • Feverfew 50-300 mg bid Level B • Riboflavin (B2) (400 mg qd) Level B • Butterbur (Petasites) 50-75 mg bid Level A • Coenzyme Q-10 (100 mg TID) Level C Holland S, et al. Evidence-based guideline update:NSAIDS and other complementary treatments for episodic migraine prevention in adults. Neurology. 2012;78:1346-1353.

• 2 migraines a week ▫ Desires fewer migraines

• Candidate for daily prevention?

• 56 yo female • Active runner • High pressure job • Insomnia

Choose preventive medication based on pharmacologic opportunity • Go for a 2-Fer! ▫ Hypertension: Beta-blocker, calcium channel blocker, ACE inhibitor or ARB ▫ Anxiety: Beta-blocker ▫ Depression and sleep disturbance: TCA ▫ Pain Disorder: Gabapentin ▫ Obesity: Topiramate

65th CAFP Annual Scientific Assembly

4/3/2013

Findings of US Headache Consortium • The following are all somewhat effective in preventing migraine compared with controls: ▫ Relaxation Training ▫ Thermal biofeedback combined with relaxation training ▫ EMG biofeedback ▫ Cognitive-behavioral therapy www.aan.com/professionals/practice/guideline.

S A T U R D A Y

• Oral inhaled dihydroergotamine • Patch for sumatriptan • CGRP Antagonist • Adolescent and Pediatric FDA Approvals for triptans • Occipital nerve stimulators • Transcranial Magnetic Stimulation (TMS)

Primary Care Resources • National Headache Foundation (NHF); www.headaches.org • http://www.icsi.org/headache/headache__di agnosis_and_treatment_of_2609.html • http://www.neurology.org/content/55/6/754 .full.pdf • http://www.montefiore.org/documents/pdfs /headache%20diary.pdf • http://itunes.apple.com/us/app/migrainediary/id348561271?mt=8 (APP for iPhone)

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Patient Resources • American Council of Headache Education (ACHE); www.achenet.org • www. HelpforHeadaches.com • www.MyMigraineConnection.com • www.Migraine.com • Hutchinson S, Peterlin BL, Menstrual Migraine, Oxford American Pain Library, Oxford University Press, 2008 • Bernstein C, McArdle E, The Migraine Brain: Your Breakthrough Guide to Fewer Headaches, Better Health, Simon & Shuster, New York, NY, 2008

Take Home Points • Be proactive (Ask) • Use validated tools to screen patients for migraine and for ongoing treatment • Goal of acute treatment is to be headache free/return to full function in 2 hours • Don’t miss the opportunity to use a preventive medication when indicated • Involve patients to identify contributors

Thank You! Questions from Audience?

ScreenMigraine • Accept the email invitation you should have received • And Let’s get started! OR email: ScreenMigraine@familydocs.org and another invitation will be sent to you.

65th CAFP Annual Scientific Assembly

Session 3: Saturday, Mary 4, 2013 | 10:45-11:30 am

Pondering Wandering and other Dementia Dilemmas (Ted and Esther Young) Christopher Flores, MD

Activity Description This interactive session will follow Ted Young’s path as he and his family as a team with his family physician family deal with his worsening dementia and identify possible solutions to improve the quality of life for the entire family. Learning Objectives - Define link between cerebrovascular disease and cognitive impairment - Identify diet and nutritional patterns associated with healthy brain function - Appraise the role of cognitive training and stress reduction in maintaining cognition Christopher V. Flores, MD, is a Board-Certified Family Physician in solo private practice in Palm Desert, California. Dr. Flores is a member of the medical staff at Eisenhower Medical Center in Rancho Mirage, California, where he also serves on the CME Committee. He completed his medical degree at the University of California, Irvine, School of Medicine and attended Stanford University as an undergraduate. Dr. Flores has lectured frequently and widely over the past three years on the topics of Primary Prevention of Dementia and Optimum Management of Dementia. He is also a teaching faculty member at the Loma Linda University School of Medicine in their Department of Family Medicine, and he is currently participating in a Fellowship in Ethnogeriatrics through the Stanford University Geriatric Education Center. Dr. Flores is a member of the CAFP’s Committee on Continuing Professional Development as serves as master faculty for the TEAM-A project. Faculty Disclosure: Dr. Flores declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. This session is supported by an unrestricted educational grant from the CAFP Foundation, in honor of John P. Crivaro, MD.

May 3-5 • San Francisco

S A T U R D A Y

4/3/2013

Pondering wandering and other dementia dilemmas… Christopher Flores, MD Asst. Clinical Professor Loma Linda University School of Medicine 2013| California Academy of Family Physicians

Learning Objectives • Recognize and address limited health literacy in dementia patients and their caregivers • Evaluate the role of new biomarkers in the diagnosis of dementia • Employ non-pharmacologic approaches to manage behavioral symptoms of dementia

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Silver Tsunami

S A T U R D A Y

US Census, 2010

Proportion of Patients with Dementia

Source: Alzheimer’s Association Trajectory Report

Ted Carmichael • 80 yo with dementia and benign prostate enlargement. • Normal lab tests • MRI of brain (1 year ago) showed atrophy but no other specific lesions. • On donepezil (Aricept) for one year • Memantine (Namenda) added 2 months ago.

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Ted Carmichael • Esther brings Ted in for routine follow-up • She lets him talk even though it is obvious that he is somewhat confused and his memory is poor • She seems hesitant to speak at first and she asks to speak to you privately after the appointment.

Medication Compliance • Ted sometimes forgets to take medications • Esther isn’t clear what medications are for • She’s left his medication administration up to him. • He is taking tamsulosin as needed for nocturia.

Health Literacy Facts • Only 13% of US population is “proficient” in health literacy • 15% of population is below “basic” level • Risk Factors associated with poor health literacy include advanced age, ethnic minorities, LEP, limited education, and poor socioeconomic status

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Health Literacy in Dementia • Patients with dementia and their caregivers are a set-up for poor health literacy • Advanced age (typically the caregiver is elderly spouse) • Cognitive impairment • Paid caregivers have poor health literacy themselves

S A T U R D A Y

Which of the following is true regarding interventions to address health literacy? 0% 0% 0% 0%

1. Educated professionals prefer written instructions at 12th grade reading level 2. Teach back technique (“show me” method) must be performed by physician 3. ASK ME 3 can be integrated into EHR 4. Video education is not beneficial in ethnic minority populations

Tools for Health Literacy • Simplify language for effective communication • “Plain Speaking” – eliminate jargon and use common English • There are proven techniques to improve understanding (Teach Back, AskMe3) • Tips on written materials

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Teach Back Technique • How well did you explain the plan? • “I want to be sure I explained the medications clearly. Can you tell me how you are going to take the medications?” • “We covered a lot of information today. Can you tell me three things that I advise you to do to improve your memory?” • “What are you going to do with medications when you get home?”

ASK ME 3 • What is my main problem? • What do I need to do? • Why is it important for me to do this?

www.npsf.org National Patient Safety Foundation

Simplify language and written materials • Studies have shown that patients (even educated ones) prefer plain and simple language when dealing with healthcare information • 6th or 7th grade reading level is ideal • Microsoft Word has a feature in the “TOOLS” section under Spelling and Grammar – “readability statistics” • Online can use “SMOG” Check (Simple Measure of Gobbledygook www.harrymclaughlin.com/SMOG.htm)

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12th grade reading level example Your physician has ordered an MRI of your brain. Please call (760) 674-3888 to schedule this imaging examination at your earliest convenience. If you are anxietyprone or claustrophobic an anxiolytic medication will be administered to you if necessary. Alert your physician if you have any implantable device or metallic materials in your body.

S A T U R D A Y

6th grade reading level Your doctor wants you to do a test to look at your brain. Please call (760) 674-3888 to set up a time to have this done. If you don’t like being in small, enclosed places like tunnels or elevators, we can give you a medicine to calm your nerves and help you get through the test. Please let us know if you have any metal inside your body (like pacemakers for the heart, or staples or clips from any operations).

Teach-back technique with Esther • Tell Ted and Esther – “This is not a test of your knowledge, it is to make sure I explained things clearly.” • Physician (holding up medication) – “What is this medication for?” • Nurse or MA (handing list of medications to patient) – “OK, please tell me what time you will give these medicines to Ted?”

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2 months later….Camille • Frustrated with her father’s declining condition – worried about her mother • Questioning diagnosis and what “more can be done”? • Has heard about new tests for diagnosing dementia – shows you internet ads promoting a new brain imaging technique.

Which of the following diagnostic studies are proven to provide benefit to patients with Alzheimer’s Dementia? 0% 0% 0% 0% 0%

1. 2. 3. 4. 5.

Amyloid imaging PET Scan Genetic Testing Volumetric Testing on MRI CSF ß-amyloid and Tau protein levels None of the above

Genetic Tests • APOE 3 and 4 • Presenilin 1 and 2 – small subset of cases of dementia that have an early onset and strong genetic component • Other genes and SNP’s

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Imaging Techniques • Fluorodeoxyglucose - FDG PET • Funcional MRI • Volumetric MRI • Amyloid Imaging

S A T U R D A Y

FDG PET

Functional MRI

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Volumetric MRI

Amyloid Imaging

Spinal Fluid Studies • Alpha-synuclein – decreased in PD, PDD, DLB, MSA; increased in AD • Beta-amyloid 1-42 – decreased in DLB and further decreased in AD • Total Tau and hyperphosphorylated Tau – elevated in AD PD=Parkinson’s Disease, PDD=Parkinson’s Disease with Dementia, DLB‐Dementia with Lewy Bodies, MSA=Multiple System Atrophy, AD=Alzheimer’s Disease

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Biomarker Summary

S A T U R D A Y

Camille and Biomarkers • Physician explains the limitations of biomarkers in primary care practice – including lack of evidence of benefit and high out-of-pocket expense • Camille is given information on academic centers with ongoing research protocols • Camille is given information on Alzheimer’s Association, useful books, and online resources for dementia

2 months later... • Both Camille and Esther come in with Ted – they are very concerned about his increasingly difficult behaviors and some combative episodes • They admit they have not had time to contact Alzheimer’s Association or look at the books you recommended

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Behavioral/Psychological Symptoms of Dementia – Why do they matter? • Frequent driver for physician visits and calls from caregivers • Nearly universal – affect almost all persons with dementia • Associated with poor patient outcomes • Associated with poor caregiver outcomes

Behavioral and Psychological Symptoms of Dementia (BPSD) • Agitation, Wandering, Combativeness, Repetitive Vocalizations, Refusal of Care, Paranoid Behavior, Delusions, Hallucinations • Associated with increased health care utilization and placement in institutionalized care

Which of the following is reported most commonly and is of most concern to caregivers? 0% 0% 0% 0%

1. 2. 3. 4.

Wandering Repetitive Questioning Refusal of care Biting and physical combativeness

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Antipsychotic medication? • Some studies support efficacy – risperidone (Risperdal) and quetiapine (Seroquel) are the most studied • Many dangers and side effects – especially with haloperidol (Haldol) • Associated with increased risk of stroke, MI, and death

S A T U R D A Y

Review overall condition • Look for underlying infections • Medication side effects • Change in environment • Sensory disturbances – Hearing? Vision? Pain?

Time for a detective… • When neighbor asked what Ted was doing wandering around he said “I need to check irrigation.” • Combative behaviors seem to be associated with Ted saying “I don’t know” and “What am I going to do”? • Prostate issues and urinary frequency nocturia has been worse

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Value of History and Physical • On questioning Esther describes increased urination, and nocturia has really been noticeable over past week • Physical exam reveals some suprapubic and lower abdominal tenderness • Urinalysis reveals blood, leukocytes, and nitrite positive • Treatment for UTI initiated

Review of medications • Urologist recently added darifenacin (Enablex) for nocturia and BPH • Esther says he does seem more disoriented since starting that medication • Darifenacin has anti-cholinergic (antimuscarinic) effects and can antagonize AChEI – this medication is discontinued

Regularly check on hearing and vision • Ted cannot hear finger rubbing next to ear • Exam shows bilateral cerumen • External canals are irrigated and cleaned out and his hearing is much improved • After UTI tx, discontinuing darifenacin, and removing cerumen there is a noticeable improvement in combative behavior

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Instituting regular hobby activities • Ted was a farmer and rancher all of his life • Currently has no connection with that life or occupation • Camille and her daughter Sarah, along with Sarah’s children, design a small “garden” of citrus trees in pots, and a small raised bed with tomatoes and herbs that Ted can “work” daily • Wandering behaviors improve

S A T U R D A Y

Telephone call one week later • Camille calls thanking you for your care and intervention ideas • Ted is better, taking daily walk for exercise, tending to his home garden, and more engaged and oriented overall • She and Esther are attending Alzheimer Association support group • No antipsychotics prescribed!

Which of the following nonpharmacologic interventions for BPSD has NOT shown evidence of benefit in clinical studies? 0% 0% 0% 0% 0%

1. Acupuncture 2. Consistent and structured daily routine 3. Regular daily exercise 4. Aromatherapy 5. Homeopathy

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Non-pharmacologic behavioral approaches • Redirecting • Distracting • Exercise • Calm, consistent predictable environment (including caregivers if possible) • Aroma therapy • Music therapy

Resources for caregivers and families • Alzheimer’s Association (both local in person services and on-line materials) • Community Centers/Senior Centers • Local Memory Care units and Assisted Living Centers • Senior Day Care Programs • County Office on Aging • Hospital-based outreach and education

Conclusions • Don’t assume health literacy • Even educated sophisticated patients prefer simple communications • Biomarkers are not ready for “primetime” • Review history for evidence of infection, medication effects, and environmental triggers • Try non-pharmacologic interventions first to manage behavioral symptoms

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Thank you! Questions?

S A T U R D A Y

16 May 3-5 â&#x20AC;˘ San Francisco

Session 4: Saturday, May 4, 2013 | 12:00-1:30 pm ER/LA Opioid REMS:

Achieving Safe Use While Improving Patient Care David E.J. Bazzo, MD and Carol Havens, MD Activity Description The Food and Drug Administration released a Risk Evaluation and Mitigation Strategy (REMS) for the use of extended-release/Long-acting opioids in July 2012. This session is in direct response to that REMS and will take participants through the first phase of “completion.” Learning Objectives At the end of this educational activity, participants should be able to: - Describe appropriate patient assessment for treatment with ER/LA opioid analgesics, evaluating risks and potential benefits of ER/LA therapy as well as possible misuse - Apply proper methods to initiate therapy, modify dose, and discontinue use of ER/LA opioid analgesics, applying best practices including accurate dosing and conversion techniques as well as appropriate discontinuation strategies. - Demonstrate accurate knowledge about how to manage ongoing therapy with ER/LA opioid analgesics, properly use evidence based tools while assessing for adverse effects - Employ methods to counsel patients and caregivers about the safe use of ER/LA opioid analgesics, including proper storage and disposal. - Review/assess general and product-specific drug information concerning ER/LA opioid analgesics, identifying potential adverse effects of ER/LA opioids. David E.J. Bazzo, MD, FAAFP, CAQSM, is a Clinical Professor of Family Medicine at the UCSD School of Medicine. He is board certified in Family Medicine and has a Certificate of Added Qualification in Sports Medicine. He is Director of the Fitness for Duty Program for the UCSD Physician Assessment and Clinical Education (PACE) Program as well as Course Director for a number of their educational offerings. He is Director of the UCSD California Correctional Healthcare Improvement Program (C-CHIP) and past Director of the UCSD Quality Improvement in Correctional Medicine (QICM) Program Dr. Bazzo has an active practice in Family and Sports Medicine in addition to his teaching and administrative roles. He is the Co-Director of the Primary Care Core Clerkship for 3rd year medical students in addition to his teaching roles in the first and second years; and faculty for the UCSD Family Medicine Residency Program; and the UCSD Sports Medicine Fellowship Program. He has an active interest in physician assessment and meaningful education at all levels of medicine - medical school through active practice. He has lectured nationally and internationally on a number of topics including Sports Medicine, Osteoarthritis, Headache, and Neurologic issues, Communications, Pain management and Physician Assessment. Dr. Bazzo is a Past President of the San Diego Academy of Family Physicians and currently serves on the Board of Directors for the San Diego County Medical Society. He is currently the Chair of the California Academy of Family Physicians Committee on Continuing Professional Development and on the American Academy of Family Physicians Subcommittee on Assembly Scientific Program. He was voted one of San Diego’s “Top Doctors” for the last 8 years in Family Medicine and in 2009, 2011 and 2012 in Sports Medicine as well by his peers. He is the 2011 recipient of the Barbara Harris Award for Educational Excellence. The selection was made by the California Academy of Family Physicians Foundation Board.

65th CAFP Annual Scientific Assembly

Dr. Carol Havens is board-certified in family medicine and addiction medicine. She is currently the director of clinical education, northern California region, Kaiser Permanente, and a staff physician in the Chemical Dependency and Recovery Program at Kaiser Permanente in Sacramento. She has served as an associate clinical professor in the department of family medicine at the University of California, Davis. Dr. Havens earned her undergraduate degree from Michigan State University and her medical degree from the University of Arizona. She completed her family medicine residency at the University of California, Davis Sacramento Medical Center. A Diplomate of the American Board of Medical Examiners and the American Board of Family Practice, with Added Qualifications in Geriatrics and certified in Addiction Medicine by the American Board of Addiction Medicine, Dr. Havens is a member of several professional societies, including the American Academy of Family Physicians, the American Medical Association, and the American Society of Addiction Medicine. She is currently member of the California Academy of Family Physicians (CAFP) Board of Directors, the chair of the California Medical Association’s Committee on CME, and a member of the CME committee for Audio-Digest. She has given numerous presentations on topics including successful smoking interventions, diagnosis and treatment of neuropathic pain, and partnerships to improve CME outcomes. She has been listed in the Best Doctors in America every year since 2005. In 2009 Dr. Havens was selected as the CAFP Foundation’s winner of the Barbara Harris Award for Excellence in Education. Drs. Bazzo and Havens are on the CO*RE Clinical Expert Panel and serve as master faculty for the initiative. Faculty Disclosure: Drs. Bazzo and Havens declare that in the past 12 months neither they, nor any members of their immediate families, have had a relevant financial interest in corporate entities supporting this meeting. This session is presented by CAFP, a member of the Collaborative on REMS Education (CO*RE), 10 interdisciplinary organizations working together to improve pain management and prevent adverse outcomes. This educational activity is supported by an independent educational grant from the ER/LA Opioid Analgesic REMS Program Companies (RPC). Please see www.er-la-opioidREMS.com for a listing the member companies. This activity is intended to be fully-complaint with the ER/LA Opioid Analgesic REMs education requirements issued by the US Food & Drug Administration (FDA).

May 3-5 • San Francisco

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4/3/2013

ER/LA OPIOID REMS: ACHIEVING SAFE USE WHILE IMPROVING PATIENT CARE Presented by CO*RE Collaboration for REMS Education www.corerems.org

Today’s Faculty David Bazzo, MD • Board certified in family medicine and sports medicine • Clinical Professor, UCSD, School of Medicine • CAFP’s 2011 Educator of the Year • Chair, CAFP Committee on Continuing Professional Development • CO*RE Clinical Advisor and Master Faculty Carol Havens, MD • Board certified in family medicine and addiction medicine • Director of Clinical Education for Northern California Kaiser Permanente • Member, CAFP Committee on Continuing Professional Development • CO*RE Clinical Advisor and Master Faculty

Our faculty declares that in the past 12 months neither they, nor members of their immediate families, have had a relevant interest in any commercial entity supporting this meeting or initiative.

CO*RE: Collaborative for REMS Education On July 9, 2012, the Food and Drug Administration (FDA) approved a Risk Evaluation and Mitigation Strategy (REMS) for extended-release (ER) and long-acting (LA) opioid medications. Founded in June, 2010, the Collaborative on REMS Education (CO*RE), a multidisciplinary collaboration of 10 Partners and three cooperating organizations, has designed a core curriculum based on needs assessment, practice gaps, clinical competencies, learner self-assessment, with shared tools, resources, and outcomes to meet the requirements of the FDA REMS Blueprint. www.core-rems.org

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Acknowledgement Presented by CAFP, a member of the Collaborative on REMS Education (CO*RE), 10 interdisciplinary organizations working together to improve pain management and prevent adverse outcomes. This educational activity is supported by an independent educational grant from the ER/LA Opioid Analgesics REMS Program Companies (RPC). Please see www.er-laopioidREMS.com for a listing of the member companies. This activity is intended to be fully compliant with the ER/LA Opioid Analgesics REMS education requirements issued by the U.S. Food & Drug Administration (FDA).

S A T U R D A Y

Learning Objectives • Describe appropriate patient assessment for treatment with ER/LA opioid

analgesics, evaluating risks and potential benefits of ER/LA therapy as well as possible misuse.

• Apply proper methods to initiate therapy, modify dose, and discontinue

use of ER/LA opioid analgesics, applying best practices including accurate dosing and conversion techniques as well as appropriate discontinuation strategies.

• Demonstrate accurate knowledge about how to manage ongoing therapy

with ER/LA opioid analgesics and properly use evidence-based tools while assessing for adverse affects.

• Employ methods to counsel patients and caregivers about the safe use

of ER/LA opioid analgesics, including proper storage and disposal.

• Review/assess general and product-specific drug information concerning

ER/LA opioid analgesics and identifying potential adverse affects of ER/LA opioids.

Products Covered By This REMS •

Brand name products • • • • • • • • • •

Avinza® morphine sulfate ER capsules Butrans® buprenorphine transdermal system Dolophine® methadone hydrochloride tablets Duragesic® fentanyl transdermal system • *Embeda® morphine sulfate/naltrexone ER capsules Exalgo® hydromorphone hydrochloride ER tablets Kadian® morphine sulfate ER capsules MethadoseTM methadone hydrochloride tablets MS Contin® morphine sulfate CR tablets Nucynta® ER tapentadol ER tablets

• • •

Opana® ER oxymorphone hydrochloride ER tablets OxyContin® oxycodone hydrochloride CR tablets †Palladone® hydromorphone hydrochloride ER capsules

Generic products • • • • • • •

Fentanyl ER transdermal systems Methadone hydrochloride tablets Methadone hydrochloride oral concentrate Methadone hydrochloride oral solution Morphine sulfate ER tablets Morphine sulfate ER capsules Oxycodone hydrochloride ER tablets

*Not currently available due to voluntary recall (still approved); †No longer marketed (still approved) FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/ downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

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WHY PRESCRIBER EDUCATION IS IMPORTANT Introduction

• Prescribers of ER/LA opioids should balance:

The benefits of prescribing ER/LA opioids to treat pain

The risks of serious adverse outcomes

Opioid Misuse/Abuse is a Major Public Health Problem • Improper use of any opioid can result in serious AEs

including overdose & death

• This risk can be greater w/ ER/LA opioids • •

ER opioid dosage units contain more opioid than IR formulations Methadone (a LA opioid) involved in 30% of prescription opioid deaths

• In 2011, 34.2 million Americans age ≥12 had used an opioid

for nonmedical use some time in their life

• In 2010, 425,247 ED visits involved nonmedical use of

opioids

SAMHSA. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD. SAMHSA. (2012). The DAWN Report: Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD. CDC. CDC Vital Signs. Prescription Painkiller Overdoses. Use and abuse of methadone as a painkiller. 2012. FDA. Questions and Answers: FDA approves a Risk Evaluation and Mitigation Strategy for Extended-Release and Long-Acting Opioid Analgesics. www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm309742.htm. 2012.

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• In 2009, 39,147 Americans died from drug poisonings • Nearly 14,800 deaths involved prescription opioids

Kochanek KD, et al. National Vital Statistics Report 2011;60:1-117. CDC Vital Signs. Prescription Painkiller Overdoses. Use and abuse of methadone as a painkiller. 2012. Warner M, et al. Drug poisoning deaths in the United States, 1980-2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. National Center for Injury Prevention and Control. Division of Unintentional Injury Prevention. Policy Impact. Prescription Painkiller Overdoses. Nov 2011.

S A T U R D A Y

Past-Yr Initiates of Specific Drugs Among Persons Age ≥12 Yrs in 2011 Number in millions

3 2.5 2

The total initiates of nonmedical Rx drug use (red bars) taken together greatly exceeds initiates of marijuana in 2010

2.6 1.9

1.5

1.2 0.9

0.7

0.7 0.4

0.5

0.2

0.05

SAMHSA. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD.

Prescriber Responsibility: To Ensure Safe & Effective Use • Appropriate prescribing practices & patient education • Expected results of this REMS education are that the

prescriber will:

• Understand how to assess patients for treatment w/ ER/LA opioids • Be familiar w/ how to initiate therapy, modify dose, & discontinue use

of ER/LA opioids

• Know how to manage ongoing therapy w/ ER/LA opioids • Know how to counsel patients & caregivers about the safe use of

ER/LA opioids, including proper storage & disposal

• Be familiar w/ general & product-specific drug information

concerning ER/LA opioids

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ASSESSING PATIENTS FOR TREATMENT WITH ER/LA OPIOID ANALGESIC THERAPY Unit I

Balance Risks Against Potential Benefits • Conduct Hx, physical exam, & appropriate testing • Comprehensive benefit-to-harm evaluation • Balance potential benefits on pain & function against potential risks • Risks include • Overdose: ER/LA dosage units contain more opioid than IR drugs • Abuse by patient or household contacts • Misuse & addiction • Physical dependence & tolerance • Interactions w/ other medications & substances • Inadvertent exposure by household contacts, especially children Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010. FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. Modified 8-28-2012. www.fda.gov/downloads/ Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

Adequately DOCUMENT all patient interactions, assessments, test results, & treatment plans

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Clinical Interview:Significant Recent Medical Hx • Illness relevant to (1) effects or (2) metabolism of opioids 1. Pulmonary disease, constipation, nausea, cognitive impairment 2. Hepatic, renal disease • Illness suggestive of substance abuse; eg: • Hepatitis • HIV • Tuberculosis • Cellulitis • STD • Trauma, burns • Cardiac disease • Pulmonary disease Chou R, et al. J Pain. 2009;10:113-30. Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. 2nd ed. Newton, MA: Inflexion, Inc., 2010. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

S A T U R D A Y

Clinical Interview: Pain & Treatment Hx • Description of pain • Location • Intensity • Quality • Onset/duration • Variations/patterns/rhythms • What relieves the pain? • What causes or increases pain? • Effects of pain • Patient’s pain & function goal

Heapy A, Kerns RD. Psychological and Behavioral Assessment. In: Raj's Practical Management of Pain. 4th ed. 2008;279-95. Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. 2nd ed. Newton, MA: Inflexion, Inc., 2010.

Clinical Interview: Pain & Treatment Hx • Pain medications • Past use • Current use

• Query state PDMP* where available to confirm patient report • Contact past providers & obtain prior medical records • Conduct UDT*

• Dosage • For opioids currently prescribed: opioid, dose, regimen, & duration • Important to determine if patient is opioid tolerant†

• General effectiveness

• Nonpharmacologic pain relief & effectiveness Heapy A, Kerns RD. Psychological and Behavioral Assessment. In: Raj's Practical Management of Pain. 4th ed. 2008;279-95. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

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Perform Thorough Physical Examination & Assessment of Presenting Pain Condition • Objective data to confirm Hx & Dx • Components of physical exam (appropriate to pain location) • General physical exam • Vital signs: overall health & comorbidities • General appearance, posture, gait, & pain behaviors • Neurologic exam • Musculoskeletal exam • Inspection • Palpation • Percussion • Auscultation • Provocative maneuvers • Cutaneous or trophic findings

• Order diagnostic tests (appropriate to complaint) Lalani I, Argoff CE. History and Physical Examination of the Pain Patient. In: Raj's Practical Management of Pain. 4th ed. 2008;177-88. Chou R, et al. J Pain. 2009;10:113-30.

Assess Each Patient’s Risk of Abuse, Including Substance Use & Psychiatric Hx • Obtain a complete Hx of current & past substance misuse • Prescription drugs • Illegal substances • Alcohol & tobacco • Substance abuse Hx does not prohibit treatment w/ ER/LA opioids but

may require additional monitoring & expert consultation/referral

• Family Hx of substance abuse & psychiatric disorders • Hx of sexual abuse

• Social history also relevant • Employment, cultural background, social network, marital history, legal history, & other behavioral patterns Chou R, et al. J Pain. 2009;10:113-30. SAMHSA. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. 2011. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

Assess Each Patient’s Risk, con’t • Be knowledgeable about risk factors for opioid abuse • Personal or family Hx of alcohol or drug abuse • Younger age • Presence of psychiatric conditions • Understand & use addiction or abuse screening tools • Assess potential risks associated w/ chronic opioid therapy • Manage patients using ER/LA opioids • Conduct a UDT • Understand limitations

Chou R, et al. J Pain. 2009;10:113-30.

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Risk Assessment Tools: Examples # of items

Tool Patients considered for long-term opioid therapy: ORT Opioid Risk Tool SOAPP® Screener & Opioid Assessment for Patients w/ Pain DIRE Diagnosis, Intractability, Risk, & Efficacy Score Characterize misuse once opioid treatments begins: PMQ Pain Medication Questionnaire COMM Current Opioid Misuse Measure PDUQ Prescription Drug Use Questionnaire Not specific to pain populations: CAGE-AID Cut Down, Annoyed, Guilty, Eye-Opener Tool, Adjusted to Include Drugs

Administered

5 By patient 24, 14, & By patient 5 7 By clinician 26 17 40

By patient By patient By clinician

By clinician

RAFFT Relax, Alone, Friends, Family, Trouble 5 By patient DAST Drug Abuse Screening Test 28 By patient Passik SD, et al. Pain Med. 2008;9:S145-66. Chou R, et al. J Pain. 2009;10:113-30. SAMHSA. Screening, Brief Intervention and Referral&toReferral Treatment in Behavioral Healthcare. Varies SBIRT Screening, Brief Intervention, to(SBIRT) Treatment* By clinician www.samhsa.gov/prevention/SBIRT/SBIRTwhitepaper.pdf. 4-1-2011.

S A T U R D A Y

Opioid Risk Tool (ORT) Mark each box that applies 1. Family Hx of substance abuse Alcohol Illegal drugs Prescription drugs 2. Personal Hx of substance abuse Alcohol Illegal drugs Prescription drugs 3. Age between 16 & 45 yrs 4. Hx of preadolescent sexual abuse 5. Psychologic disease

ADD, OCD, bipolar, schizophrenia Depression

Female Male  1  2  4

 3  3  4

 3  4  5

 1  3

 1  0

 2  1

• Administer • On initial visit • Prior to opioid therapy • Scoring (risk) • 0-3: low • 4-7: moderate • ≥8: high

Scoring totals: Webster LR, Webster RM. Pain Med. 2005;6:432-42.

SOAPP • Identifies patients as at high, moderate, or low risk for misuse

of opioids prescribed for chronic pain

• How is SOAPP administered? • Usually self-administered in waiting room, exam room, or prior to an office visit • May be completed as part of an interview w/ a nurse, physician, or psychologist • Prescribers should have a completed & scored SOAPP while making opioid treatment decisions

SOAPP® Monitoring Recommendations. https://painedu.org/soapp/SOAPP_Monitoring_Recommendations.pdf The SOAPP® Version 1.0 Tutorial. https://painedu.org/soapp-tutorial_01.asp

May 3-5 • San Francisco

4/3/2013

When to Consider a Trial • Pain is moderate to severe • Failed to adequately respond to nonopioid & nondrug interventions • Continuous, around-the-clock opioid analgesic is needed for

an extended period of time

• Potential benefits are likely to outweigh risks • Consider referral to pain or addiction specialist for patients where risks outweigh benefits • No alternative therapy is likely to pose as favorable a

balance of benefits to harms Chou R, et al. J Pain. 2009;10:113-30.

Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

When to Consider a Trial • 60-yr-old w/ chronic disabling OA pain • Nonopioid therapies not effective, IR opioids provided some relief but experienced end-of-dose failure • No psychiatric/medical comorbidity or personal/family drug abuse Hx • High potential benefits relative to potential risks • Could prescribe opioids to this patient in most settings w/ routine

monitoring

• 30-yr-old w/ fibromyalgia & recent IV drug abuse • High potential risks relative to benefits (opioid therapy not 1st line for

fibromyalgia)

• Requires intensive structure, monitoring, & management by clinician w/

expertise in both addiction & pain

• Undertake only if risks can be adequately managed

Chou R, et al. J Pain. 2009;10:113-30.

When to Consider a Trial • Selection of patients between these 2 extremes

requires:

• Careful assessment & characterization of patient risk • Structuring of care to match risk • In patients w/ Hx of substance abuse or a psychiatric comorbidity, this may require assistance from experts in managing pain, addiction, or other mental health concerns • In some cases opioids may not be appropriate or should be deferred until the comorbidity has been adequately addressed • Consider referral

Chou R, et al. J Pain. 2009;10:113-30.

9 65th CAFP Annual Scientific Assembly

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Referring High-Risk Patients • Prescribers should • Understand when to appropriately refer high-risk patients to pain management or addiction specialists • Also check your state regulations for requirements

Chou R, et al. J Pain. 2009;10:113-30.

S A T U R D A Y

Special Considerations: Elderly Patients • Does patient have medical problems that increase risk

of opioid-related AEs?

• Respiratory depression more likely in elderly, cachectic, or debilitated

patients

• Altered PK due to poor fat stores, muscle wasting, or altered clearance • Monitor closely, particularly when • Initiating & titrating ER/LA opioids • Given concomitantly w/ other drugs that depress respiration • Reduce starting dose to 1/3 to 1/2 the usual dosage in debilitated, non-opioid-

tolerant patients • Titrate dose cautiously • Older adults more likely to develop constipation • Routinely initiate a bowel regimen before it develops

• Is patient/caregiver likely to manage opioid therapy

responsibly?

American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. J Am Geriatr Soc. 2009;57:1331-46. Chou R, et al. J Pain. 2009;10:113-30.

Special Considerations:Children • Safety & effectiveness of most ER/LA opioids* in pediatric

patients <18 yrs not established

• Pediatric analgesic trials pose challenges

*Transdermal fentanyl approved in children aged ≥2 yrs

• Most opioid studies in children focus on inpatient safety • Opioids are common sources of drug error • Pediatric opioid indications are primarily life-limiting

conditions

• Few children w/ chronic pain due to non-life-limiting conditions should

receive opioids

• Consult pediatric palliative care team or pediatric pain

specialist when prescribing opioids to children • Or refer to specialized multidisciplinary pain clinic

Berde CB, et al. Pediatrics. 2012;129:354-64. Gregoire MC, et al. Pain Res Manag 2013;18:47-50. Mc Donnell C. Pain Res Manag. 2011;16:93-8. Slater ME, et al. Pain Med. 2010;11:207-14.

May 3-5 • San Francisco

4/3/2013

INITIATING THERAPY, MODIFYING DOSING, & DISCONTINUING USE OF ER/LA OPIOID ANALGESICS Unit II

Federal & State Regulations • Comply w/ federal & state laws & regulations that govern the

use of opioid therapy for pain • Federal

• Code of Federal Regulations, Title 21 Section 1306: rules governing

the issuance & filling prescriptions pursuant to section 309 of the Act (21 USC 829) • www.deadiversion.usdoj.gov/21cfr/cfr/2106cfrt.htm

• United States Code (USC) - Controlled Substances Act, Title 21,

Section 829: prescriptions

• www.deadiversion.usdoj.gov/21cfr/21usc/829.htm

• State • Database of state statutes, regulations, & policies for pain management • www.medscape.com/resource/pain/opioid-policies • www.painpolicy.wisc.edu/database-statutes-regulations-other-policiespain-management

Initiating Treatment • Prescribers should regard initial treatment as a therapeutic

trial

• May last from several wks to several months • Decision to proceed w/ long-term treatment should be intentional &

based on careful consideration of outcomes during the trial • Progress toward meeting therapeutic goals • Presence of opioid-related AEs • Changes in underlying pain condition • Changes in psychiatric or medical comorbidities

• Identification of aberrant drug-related behavior, addiction, or diversion

Chou R, et al. J Pain. 2009;10:113-30.

65th CAFP Annual Scientific 11 Assembly

4/3/2013

ER/LA Opioid-Induced Respiratory Depression • Chief hazard of opioid agonists, including ER/LA opioids • If not immediately recognized & treated, may lead to respiratory arrest & death • Greatest risk: initiation of therapy or after dose increase • Manifested by reduced urge to breathe & decreased

respiration rate

• Cheyne-Stokes respiration • CO2 retention can exacerbate opioid sedating effects

• Instruct patients/family members to call 911* • Managed w/ close observation, supportive measures, & opioid antagonists, depending on patient’s clinical status

Chou R, et al. J Pain. 2009;10:113-30. FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafety InformationforPatientsandProviders/UCM311290.pdf

S A T U R D A Y

ER/LA Opioid-Induced Respiratory Depression • More likely to occur • In elderly, cachectic, or debilitated patients • Contraindicated in patients w/ respiratory depression or conditions that

increase risk

• If given concomitantly w/ other drugs that depress respiration

• Reduce risk • Proper dosing & titration are essential • Do not overestimate dose when converting from another opioid product • Can result in fatal overdose w/ first dose

• Instruct patients to swallow tablets/capsules whole • Dose from cut, crushed, dissolved, or chewed tablets/capsules

may be fatal, particularly in opioid-naïve individuals

Initiating & Titrating: Opioid-Naïve Patients • Drug & dose selection is critical • Some ER/LA opioids or dosage forms only for opioid-tolerant patients • Check individual drug PI

• Monitor patients closely for respiratory depression • Especially within 24-72 h of initiating therapy & after dose

increase

• Individualize dosage by titration based on efficacy, tolerability,

& presence of AEs

• Check ER/LA opioid product PI for minimum titration intervals • Supplement w/ IR analgesics (opioids & nonopioid) if pain is not

controlled during titration

The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of life-threatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf. 2012. Chou R, et al. J Pain. 2009;10:113-30. FDA. Blueprint for Prescriber Education for ER/LA Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafety InformationforPatientsandProviders/UCM311290.pdf

May 3-5 • San Francisco

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Initiating: Opioid-Tolerant Patients • If opioid tolerant—no restrictions on which products

can be used

• Patients considered opioid tolerant are taking at least • 60 mg oral morphine/day • 25 mcg transdermal fentanyl/hr • 30 mg oral oxycodone/day For 1 wk or longer • 8 mg oral hydromorphone/day • 25 mg oral oxymorphone/day • An equianalgesic dose of another opioid • Still requires caution when rotating a patient on a IR opioid

to a different ER/LA opioid

Opioid Rotation • Definition • Change from an existing opioid regimen to another opioid w/ the goal of improving therapeutic outcomes • Rationale • Differences in pharmacologic or other effects make it likely that a switch will improve outcomes • Effectiveness & AEs of different mu opioids vary among patients • Patients show incomplete cross-tolerance to new opioid • Patient tolerant to 1st opioid can have improved analgesia from 2nd opioid at a dose lower than calculated from an EDT

Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25. Knotkova H, et al. J Pain Symptom Manage. 2009;38:426-39. Pasternak GW. Neuropharmacol. 2004;47(suppl 1):312-23.

Reasons for Opioid Rotation • Poor opioid responsiveness • Dose titration yields intolerable/unmanageable AEs • Poor analgesic efficacy despite dose titration • Other potential reasons • Patient desire or need to try a new formulation • Cost or insurance issues • Adherence issues • Concern about abuse or diversion • Change in clinical status requires an opioid w/ different PK • Problematic drug-drug interactions

Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25. Knotkova H, et al. J Pain Symptom Manage. 2009;38:426-39. Cruciani R, et al. Oncology. 2005;19:1-4.

65th CAFP Annual Scientific 13 Assembly

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Equianalgesic Doses • Opioid rotation requires calculation of an approximate

equianalgesic dose

• Equianalgesic dose is a construct derived from relative opioid

potency estimates

• Potency refers to dose required to produce a given effect

• Relative potency estimates • Ratio of doses necessary to obtain roughly equivalent effects • Calculate across drugs or routes of administration • Relative analgesic potency is converted into an equianalgesic dose by applying the dose ratio to a standard

Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25.

S A T U R D A Y

Knotkova H, et al. J Pain Symptom Manage. 2009;38:426-39.

Equianalgesic Dose Tables (EDT) • Many different versions: • Published • Online • Online interactive • Smart-phone apps • Vary in terms of • Equianalgesic values • Whether ranges are used • Which opioids are included • May or may not include transdermal opioids, rapid-onset fentanyl, ER/LA opioids, or opioid agonist-antagonists Knotkova H, et al. J Pain Symptom Manage. 2009;38:426-39. Shaheen PE, et al. J Pain Symptom Manage. 2009;38:409-17. LR, et al. Pain Med. 2012;13:562-70. Haffey F, et al. Drug Saf. 2013;36:111-7.

Webster

Example of an EDT Drug

Oral

Morphine

30 mg 10 mg

Parenteral Conversion ratio to oral morphine Parenteral morphine: 3 times as potent as oral morphine

Oxycodone

20 mg NA

Oral oxycodone: ~1.5 times as potent as oral morphine

Hydrocodone

20 mg NA

Oral hydrocodone: ~1.5 times as potent as oral morphine

Hydromorphon 7.5 e mg

1.5 mg

Oral hydromorphone: ~4-7 times as potent as oral morphine Parenteral hydromorphone: 20 times as potent as oral morphine

Fentanyl

15 mcg/hr

Transdermal fentanyl: ~80 times as potent as morphine (based on studies converting from morphine to fentanyl)

Periyakoil V. End of Life Online Curriculum. Pain control: opioid conversion module. http://endoflife.stanford.edu/M11_pain_control/intro_m01.html. 2008.

May 3-5 • San Francisco

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Limitations of EDTs • Single-dose potency studies using a specific route,

conducted in patients w/ limited opioid exposure

• Did not consider • Chronic dosing • High opioid doses • Other routes • Different pain types • Comorbidities or organ dysfunction • Gender, ethnicity, advanced age, or concomitant medications • Direction of switch from 1 opioid to another • Interpatient variability in pharmacologic response to opioids • Incomplete cross-tolerance among mu opioids Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25. Knotkova H, et al. J Pain Symptom Manage. 2009;38:426 -39. Shaheen PE, et al. J Pain Symptom Manage. 2009;38:409-17. Webster LR, et al. Pain Med. 2012;13:562-70.

Utilizing Equianalgesic Doses Incomplete cross-tolerance & inter-patient variability require use of conservative dosing when converting from one opioid to another • Equianalgesic dose a starting point for opioid rotation

• Intended as general guide • Calculated dose of new drug based on EDT must be reduced, then titrate the new opioid as needed • Closely follow patients during periods of dose adjustments • Follow conversion instructions in individual ER/LA opioid PI, when

provided

Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25.

Knotkova H, et al. J Pain Symptom Manage. 2009;38:426-39.

Guidelines for Opioid Rotation • Calculate equianalgesic dose of new opioid from

EDT

• Reduce calculated equianalgesic dose by 25%-50%* • Select % reduction based on clinical judgment • Closer to 50% reduction if patient is • Receiving a relatively high dose of current opioid regimen • Elderly or medically frail • Closer to 25% reduction if patient • Does not have these characteristics • Is switching to a different administration route of same drug

*75%-90% reduction for methadone Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25.

65th CAFP Annual Scientific 15 Assembly

4/3/2013

Guidelines for Opioid Rotation • If switching to methadone • Reduce calculated equianalgesic dose by 75%-90% • Patients on very high opioid doses (eg, ≥1,000 mg morphine equivalents/d), be cautious converting to methadone ≥100 mg/d • Consider inpatient monitoring, including serial EKG monitoring • If switching to transdermal • fentanyl, calculate dose conversion based on equianalgesic dose ratios included in the PI • buprenorphine, follow instructions in the PI

S A T U R D A Y

Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25.

Guidelines for Opioid Rotation • Have a strategy to frequently assess • Analgesia • AEs

• Withdrawal symptoms

• Titrate new opioid dose to optimize outcomes &

safety

• If supplemental “rescue dose” for BTP is used during

titration, calculate this at 5%-15% of total daily opioid dose & administer at an appropriate interval

•

If oral transmucosal fentanyl product is used as a rescue, begin dosing lowest dose irrespective of baseline opioid dose Fine PG, et al. J Pain Symptom Manage. 2009;38:418-25.

Breakthrough Pain in Chronic Pain Pts • Patients on stable ATC opioids may experience BTP • Progression of condition or a new or unrelated pain • Therapies • Directed at cause of BTP or precipitating factors • Nonspecific symptomatic therapies to lessen impact of BTP • Consider adding • PRN IR opioid trial based on analysis of benefit vs risk • Risk for aberrant drug-related behaviors • High-risk: only in conjunction w/ frequent monitoring & follow-up • Low-risk: w/ routine follow-up & monitoring

• Nonopioid drug therapies • Nonpharmacologic treatments Chou R, et al. J Pain. 2009;10:113-30.

May 3-5 • San Francisco

4/3/2013

Reasons for Discontinuing ER/LA Opioids • Makes no progress toward therapeutic goals • Intolerable & unmanageable AEs • Serious nonadherence to treatment plan or unsafe behavior • 1 or 2 episodes of increasing dose without prescriber knowledge • Sharing medications • Unapproved opioid use to treat another symptom (eg, insomnia) • Aberrant behaviors suggestive of addiction &/or diversion • Use of illicit drugs or unprescribed opioids • Repeatedly obtaining opioids from multiple outside sources • Prescription forgery • Multiple episodes of prescription loss • Pain level decreases in stable patients Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

Taper Dose When Discontinuing • Taper dose to avoid opioid withdrawal in physically

dependent patient

• Outpatient setting in patients without severe medical or

psychiatric comorbidities

• Rehabilitation setting if patient unable to reduce opioid dose in a less

structured setting

• When aberrant drug-related behaviors continue, may need to enforce

tapering efforts

• Approaches range from slow 10% dose reduction/wk to

more rapid 25%-50% reduction every few days

Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

Taper Dose When Discontinuing • Factors that influence the reduction rate • Reason for decision to discontinue the opioid • Presence of medical & psychiatric comorbidities • Dose • Initial rate more rapid at high doses (eg, >200 mg/d morphine equivalent) • Slower rate at low doses (eg, 60-80 mg/d morphine equivalent)

• Occurrence of withdrawal symptoms as taper is initiated

• After taper, continue, substance use, or • Continue to treat pain w/ nonopioids & psychiatric disorders • If aberrant behaviors may be due to addiction • Addiction treatment resources should be made available • Motivate patient to seek addiction treatment

Chou R, et al. J Pain. 2009;10:113-30.

65th CAFP Annual Scientific 17 Assembly

4/3/2013

MANAGING THERAPY WITH ER/LA OPIOID ANALGESICS Unit III

S A T U R D A Y

Informed Consent • Before initiating a trial of opioid analgesic therapy, obtain

informed consent to establish

• Analgesic & functional goals of treatment • Expectations • Potential risks • The potential for & how to manage: • Common opioid-related AEs (eg, constipation, nausea, sedation) • Other serious risks (eg, abuse, addiction, respiratory depression,

overdose)

• AEs after long-term or high-dose opioid therapy (eg, hyperalgesia,

endocrinologic or sexual dysfunction)

• Alternatives to opioids

Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

Consider Patient-Prescriber Agreements (PPA) • Document signed by both patient & prescriber at time an

opioid is prescribed

• Clarify treatment plan & goals of treatment w/ patient, patient’s

family, & other clinicians involved in patient’s care

• Assist in patient education • Inform patients about the risks & benefits • Document patient & prescriber responsibilities

Chou R, et al. J Pain. 2009;10:113-30.

May 3-5 • San Francisco

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Consider a PPA • Reinforce expectations for appropriate & safe opioid use • Obtain opioids from a single prescriber • Fill opioid prescriptions at a designated pharmacy • Safeguard opioids • Do not store in medicine cabinet • Keep locked (eg, use a medication safe) • Do not share or sell medication

• Instructions for disposal when no longer needed • Commitments to return for follow-up visits • Comply w/ appropriate monitoring • eg, random UDT & pill counts

• Frequency of prescriptions • Enumerate behaviors that may lead to opioid discontinuation • An exit strategy Chou R, et al. J Pain. 2009;10:113-30.

Monitor Patients During Opioid Therapy • Therapeutic risks & benefits do not remain static • Affected by change in underlying pain condition, coexisting disease, or psychologic/social circumstances • Identify patients • Who are benefiting from opioid therapy • Who might benefit more w/ restructuring of treatment or receiving additional services (eg, addiction treatment) • Whose benefits from treatment are outweighed by harms • Periodically assess continued need for opioid analgesic • Reevaluate underlying medical condition if clinical presentation changes

Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

Monitor Patients During Opioid Therapy • Periodically evaluate • Pain control • Document pain intensity, pattern, & effects

• Functional outcomes • Document level of functioning • Assess progress toward achieving therapeutic goals

• Health-related QOL • AE frequency & intensity • Adherence to prescribed therapies

• Patients requiring more frequent monitoring • High risk • On high opioid doses Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010.

65th CAFP Annual Scientific 19 Assembly

4/3/2013

Anticipate & Treat Common AEs • Constipation is the most common opioid-related AE • Most patients develop constipation after opioid initiation or dose increases • Resolution of constipating effects often does not occur w/ continued exposure • In older adults or patients w/ reasons to develop constipation, initiate a bowel regimen before constipation develops • Increase fluid & fiber intake, stool softeners, & laxatives • Opioid antagonists may help prevent/treat opioid-induced bowel

dysfunction

• Nausea or vomiting tend to diminish over days or wks • Oral & rectal antiemetic therapies

S A T U R D A Y

Chou R, et al. J Pain. 2009;10:113-30.

Anticipate & Treat Common AEs • Sedation or clouded mentation after initiation tends to wane

over time

• When initiating or changing doses, counsel patients about

driving & work & home safety

• Counsel patients on effects & risks of concomitant exposure to other

drugs & substances w/ sedating effects

• Chronic ER oral opioid use associated w/ hypogonadism &

decreased dehydroepiandrosterone sulfate levels

• Test patients who report symptoms for hormonal deficiencies • Eg, decreased libido, sexual dysfunction, or fatigue

• Pruritus & myoclonus • Treatment strategies for either condition largely anecdotal Chou R, et al. J Pain. 2009;10:113-30.

Monitor Adherence and Aberrant Behavior • Routinely monitor patient adherence to treatment plan • Recognize & document aberrant drug-related behavior • In addition to patient self-report also use: • State PDMPs, where available • UDT • Positive for nonprescribed drugs • Positive for illicit substance • Negative for prescribed opioid • Family member or caregiver interviews • Monitoring tools such as the COMM, PADT, PMQ, or PDUQ • Medication reconciliation (eg, pill counts)

PADT=Pain Assessment & Documentation Tool Chou R, et al. J Pain. 2009;10:113-30.

May 3-5 • San Francisco

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Address Aberrant Drug-Related Behavior • Behavior outside the boundaries of agreed-on treatment

plan; eg:

Behaviors that are less indicative of Behaviors that are more indicative aberrancy of aberrancy Unsanctioned dose escalations or other noncompliance w/ therapy on 1 or 2 occasions Unapproved use of the drug to treat another symptom Openly acquiring similar drugs from other medical sources

Multiple dose escalations or other noncompliance w/ therapy despite warnings Prescription forgery Obtaining prescription drugs from nonmedical sources

• Address & refer for substance abuse treatment as indicated Fleming MF, et al. Pain Med. 2008;9:1098-106. Passik SD, et al. J Pain Symptom Manage. 2011;41:116-25. Portenoy RK. J Law Med Ethics. 1996;24:296-309. Passik SD, et al. Clin J Pain. 2006;22:173-81. Chou R, et al. J Pain. 2009;10:113-30.

State Prescription Monitoring Programs (PDMPs) • 49 states & 1 territory have legislation authorizing a

PDMP

• 43 states have an operational PDMP • Individual state laws determine • Who has access to PDMP information • Which drug schedules are monitored • Which agency administers the PDMP • Whether prescribers are required to register w/ the PDMP • Whether prescribers are required to access PDMP information in certain

circumstances

• Whether unsolicited PDMP reports are sent to prescribers National Alliance For Model State Drug Laws. Status of Prescription Drug Monitoring Programs. www.namsdl.org/documents/PMPProgramStatus01022013.pdf Alliance of States with Prescription Monitoring Programs. www.pmpalliance.org/pdf/pmp_status_map_2012.pdf Alliance of States with Prescription Monitoring Programs. Prescription Monitoring Frequently Asked Questions (FAQ). www.pmpalliance.org/content/prescription-monitoring-frequently-asked-questions-faq

PDMP Benefits • Record of a patient’s controlled substance prescriptions

dispensed

• Some are available online 24/7 • Opportunity to discuss w/ patient

• Provide warnings of potential misuse/abuse • Existing prescriptions not reported by patient • Multiple prescribers/pharmacies • Drugs that increase overdose risk when taken together • Patient pays for abusable drugs w/ cash • Prescribers can check their own prescribing Hx

Perrone J, et al. N Engl J Med. 2012;366:2341-3. Gugelmann HM, et al. JAMA. 2011;306:2258-9. Clark T, et al. Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices. 2012. The Prescription Drug Monitoring Program Center of Excellence, Heller School for Social Policy & Management, Brandeis University. www.pdmpexcellence.org/sites/all/pdfs/Brandeis_PDMP_Report_final.pdf.

65th CAFP Annual Scientific 21 Assembly

4/3/2013

PDMP Unsolicited “Patient Threshold Reports” • Available in some states • Automatically generated on patients who cross certain

thresholds

• E-mailed to prescribers to whom prescriptions were attributed • Review records to confirm it is your patient & you wrote the

prescription(s) attributed to you

• If inaccurate, contact PDMP • If you wrote the prescription(s), patient safety may dictate need to

discuss the patient w/ other prescribers listed on report

• Decide who will continue to prescribe for the patient & who might address

drug abuse concerns

Clark T, et al. Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices. 2012. The Prescription Drug Monitoring Program Center of Excellence, Heller School for Social Policy & Management, Brandeis University. www.pdmpexcellence.org/sites/all/pdfs/Brandeis_PDMP_Report_final.pdf.

S A T U R D A Y

Rationale for Urine Drug Testing (UDT) • Help to identify drug misuse/addiction • Prior to starting opioid treatment • Assist in assessing adherence during opioid therapy • As requirement of therapy w/ a opioid • Support decision to refer • Testing frequency is based on clinical judgment • If patient displays aberrant behavior, sufficient to document adherence to treatment plan • Check state regulations for requirements

Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. 2010. Ed 4. SAMHSA. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No.(SMA) 12-4668. Rockville, MD: SAMHSA, 2012. Chou R, et al. J Pain. 2009;10:113-30. Gourlay DL, et al. Compliance monitoring in chronic pain management. In: Bonica’s Management of Pain. 4th ed. Gourlay DL, et al. Pain Med. 2009;10 Suppl 2:S115-23.

Main Types of UDT Methods • Initial testing w/ IA drug panels • Classify substance as present or absent according to cutoff • Many do not identify individual drugs within a class • Subject to cross-reactivity • Either lab based or at POC • Identify specific drugs &/or metabolites w/

sophisticated lab-based testing; eg, GC/MS or LC/MS • Specifically confirm the presence of a given drug • eg, morphine is the opiate causing a positive IA

• Identify drugs not included in IA tests • When results are contested

IA=immunoassay GC/MS=gas chromatography/ mass spectrometry LC/MS=liquid chromatography/ mass spectrometry

Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. 2010. Ed 4. Cone EJ, et al. Postgrad Med. 2009;121:91-102. SAMHSA. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No.(SMA) 12-4668. Rockville, MD: SAMHSA, 2012.

May 3-5 • San Francisco

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Detecting Opioids by UDT • The most common opiate IAs • Detects “opiates” • Morphine & codeine, but does not distinguish which is present

• Do not reliably detect semisynthetic opioids • Specific IA can be ordered for some (eg, oxycodone)

• Do not detect synthetic opioids (eg, methadone, fentanyl) • Only specifically directed IA will detect synthetics

• GC/MS or LC/MS will identify specific opioids • Confirm presence of a drug causing a positive IA • Identify opioids not included in IAs, including semisynthetic & synthetic opioids • Contact lab when looking for a specific opioid

Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. 2010. Ed 4.

Interpretation of UDT Results • Positive result • Demonstrates recent use

• Most drugs in urine have detection times of 1-3 d • Chronic use of lipid-soluble drugs: test positive for ≥1 wk

• Does not diagnose

• Drug addiction, physical dependence, or impairment

• Does not provide enough information to determine • Exposure time, dose, or frequency of use

• Negative result for prescribed opioid • Does not diagnose diversion

• More complex than presence or absence of a drug in urine

• May be due to maladaptive drug-taking behavior • Bingeing, running out early • Other factors: eg, cessation of insurance, financial difficulties

Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. 2010. Ed 4. SAMHSA. Clinical Drug Testing in Primary Care. TAP 32. HHS Publication No.(SMA) 12-4668. 2012. Gourlay DL, et al. Pain Med. 2005;6:107-12. Gourlay D, et al. Clin J Pain. 2010;26:358. Nafziger AN, et al. Clin J Pain. 2009;25:73-9.

Interpretation of UDT Results • Be aware • Testing technologies & methodologies evolve • Differences exist between IA test menu panels vary • Cross-reactivity patterns • Maintain list of all patient’s prescribed & OTC drugs • Assist to identify false-positive results

• Cutoff levels • Time taken to eliminate drugs • Document time of last use & quantity of drug(s) taken

• Opioid metabolism may explain presence of apparently unprescribed drugs

Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. Ed 4. 2010.

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4/3/2013

Examples of Metabolism of Opioids Codeine

Morphine

Hydrocodone

Hydromorphone

Oxycodone

Oxymorphone

6-MAM

Heroin

t½=25-30 min

t½=3-5 min

Not comprehensive pathways, but may explain presence of apparently unprescribed drugs 6-MAM=6-monoacetylmorphine Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. Ed 4. 2010.

S A T U R D A Y

Interpretation of UDT Results • Use UDT results in conjunction w/ other clinical information • Investigate unexpected results • Discuss w/ the lab • Schedule appointment w/ patient to discuss unexpected/abnormal results • Chart results, interpretation, & action • Do not ignore the unexpected positive result • May necessitate closer monitoring &/or referral to a specialist

Gourlay DL, et al. Urine Drug Testing in Clinical Practice. The Art & Science of Patient Care. Ed 4. 2010.

Be Ready to Refer • Be familiar w/ referral sources for abuse or

addiction that may arise from use of ER/LA opioids • SAMHSA substance abuse treatment facility locator • http://findtreatment.samhsa.gov/TreatmentLocator/faces/qui ckSearch.jspx • SAMHSA mental health treatment facility locator • http://findtreatment.samhsa.gov/MHTreatmentLocator/faces/ quickSearch.jspx

May 3-5 • San Francisco

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COUNSELING PATIENTS & CAREGIVERS ABOUT THE SAFE USE OF ER/LA OPIOID ANALGESICS Unit IV

• Use Patient

Counseling Document to help counsel patients • Download

www.er-laopioidrems.com/IwgUI/re ms/pdf/patient_counselin g_document.pdf

• Order hard copies

www.minneapolis.cenve o.com/pcd/SubmitOrders .aspx

Counsel Patients About Proper Use • Explain • Product-specific information about the prescribed ER/LA opioid • How to take the ER/LA opioid as prescribed • Importance of adherence to dosing regimen, how to handle missed doses, & to contact their prescriber should pain not be controlled • Instruct patients/caregivers to • Read the ER/LA opioid Medication Guide received from pharmacy every time an ER/LA opioid is dispensed • Tell all their doctors about all medications they are taking

FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. Available at www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of life-threatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf.

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Counsel Patients About Proper Use • Counsel patients/caregivers • On the most common AEs of ER/LA opioids • About the risk of falls, working w/ heavy machinery, & driving • Call the prescriber for advice about managing AEs • Inform the prescriber about AEs

• Prescribers should report serious AEs to the FDA

• www.fda.gov/downloads/Safety/MedWatch/HowToR eport/DownloadForms/UCM082725.pdf • 1-800-FDA-1088

S A T U R D A Y

Warn Patients • Never break, chew, or crush an oral ER/LA

tablet/capsule, or cut or tear patches prior to use • May lead to rapid release of ER/LA opioid causing overdose & death • When a patient cannot swallow a capsule whole, prescribers should

refer to PI to determine if appropriate to sprinkle contents on applesauce or administer via feeding tube

• Use of other CNS depressants* w/ ER/LA opioids

can cause overdose & death

• Use other CNS depressants, including other opioids, under the

instruction of their prescriber

*eg, sedative-hypnotics & anxiolytics, alcohol, illegal drugs FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

Warn Patients • ER/LA opioids AEs can lead to

death

TAKE 1 TABLET BY MOUTH EVERY 12 HOURS OXYCONTIN 10 MG Qty: 60 TABLETS TABLET

• Take exactly as directed • Counsel patients/caregivers on risk

factors, signs, & symptoms of overdose & opioid-induced respiratory depression, GI obstruction, & allergic reactions • Call 911 or poison control 1-800-222-1222

• Not to abruptly discontinue or reduce the ER/LA

opioid

• Discuss how to safely taper the dose when discontinuing FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

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Optional slide

Dial 911 in the US or Canada WARNING: A person who at first only seems to be overmedicated may get much worse. They should be kept awake & watched closely. If a child or pet ever swallows an opioid that was not prescribed for them, it is always an emergency. Call for help immediately.

Opioids911-Safety: Help for Safely Using Opioid Pain Relievers. Pain Treatment Topics. http://opioids911.org/emergencies.php

Protecting the Community • Caution patients • Sharing ER/LA opioids w/ others may cause them to have serious AEs • Including death

• Selling or giving away ER/LA opioids is

against the law

• Store ER/LA opioids in a safe & secure place away from

children, family members, household visitors, & pets • Eg, a medication safe

• Protect ER/LA opioids from theft • Dispose of any ER/LA opioids when no longer needed • Read product-specific disposal information included w/ ER/LA opioid

Source of Most Recent Rx Opioids Among PastYr Users Drug dealer 3.9%

>1 doctor 1.9%

Bought on Internet 0.3%

Other 5.0%

Bought/ took: friend/ relative 16.6%

Free: friend/ relative 54.2%

1 doctor 18.1%

SAMHSA. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD.

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Educate Patients & Families • Rx medicines should only be taken when prescribed to you

by a provider

• Taking a pill prescribed for someone else is drug abuse—& illegal—

even just once

• Misusing Rx drugs can be as dangerous as illegal “street”

drugs

• Mixing Rx opioids w/ alcohol or w/ sedatives/hypnotics is

potentially fatal

Apa-Hall P, et al. J Sch Nurs. 2008;24(suppl):S1-16. Paulozzi LJ, et al. Pain Med. 2012;13:87-95. Med. 2011;12 Suppl 2:S26-35.

Webster LR, et al. Pain

S A T U R D A Y

Educate Parents Not in My House:What to Do • Step 1: MONITOR • Note how many pills in each prescription

bottle or pill packet

• Keep track of refills for all household

members • If your teen has been prescribed a drug,

coordinate & monitor dosages & refills

• Make sure friends & relatives—especially

grandparents—are aware of the risks

• If your teen visits other households, talk to the families

about safeguarding their medications

The Partnership at DrugFree.org. Rx Abuse: Not in My House. http://notinmyhouse.drugfree.org/steps.aspx

Educate Parents Not in My House:What to Do

• Step 2: SECURE • Do not store prescription meds in the medicine cabinet • Keep meds in a safe place (eg, locked cabinet) • Tell relatives, especially grandparents, to lock meds or keep

in a safe place

• Encourage parents of your teen’s friends to secure meds

• Step 3: DISPOSE • Take inventory of all prescription drugs in your home • Discard expired or unused meds The Partnership at DrugFree.org. Rx Abuse: Not in My House. http://notinmyhouse.drugfree.org/steps.aspx

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ER/LA Opioid Drug Disposal • 6th National Prescription Drug

Take-Back Day: “Got Drugs?” • Locations TBA • Check back at

www.deadiversion.usdoj.gov/ drug_disposal/takeback/index.html

• Drug drop boxes in some local

police departments

• http://rxdrugdropbox.org/ or • www.americanmedicinechest.com/ or • www.takebacknetwork.com/local_efforts.html

Prescription Drug Disposal •

To find a box near you

Video demonstration: www.smarxt disposal.net/ index.html

If take-back program or drop box unavailable, throw out in household trash • Take drugs out of original containers • Mix w/ undesirable substance

• Eg, used coffee grounds or kitty litter • Less appealing to children/pets, & unrecognizable to people who intentionally go through your trash

• Place in sealable bag, can, or other container

• Prevent leaking or breaking out of garbage bag • Before throwing out a medicine container

• Scratch out identifying info on label FDA. How to Dispose of Unused Medicines. 2011. www.fda.gov/downloads/Drugs/ ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-theCounterMedicines/ucm107163.pdf SMARxT Disposal. A prescription for a healthy planet. www.smarxtdisposal.net/index.html

Prescription Drug Disposal • FDA lists especially harmful medicines—in some cases

fatal w/ just 1dose—if taken by someone other than the patient

• Instruct patients to check medication guide • Flush down sink/toilet if no available take-back program • As soon as they are no longer needed

• So cannot be accidentally taken by children, pets, or others • Includes transdermal adhesive skin patches • Used patch worn for 3 d still contains enough opioid to harm/kill a child • Dispose of used patches immediately after removing from skin

• Fold patch in half so sticky sides meet, then flush down toilet • Do NOT place used or unneeded patches in household trash • Exception is Butrans: can seal in Patch-Disposal Unit provided & dispose of in the trash

www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ ucm186187.htm

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GENERAL DRUG INFORMATION FOR ER/LA OPIOID ANALGESIC PRODUCTS Unit V

S A T U R D A Y

General ER/LA Opioid Drug Information • Prescribers should be knowledgeable about general

characteristics, toxicities, & drug interactions for ER/LA opioid products; eg: • ER/LA opioid analgesic products are scheduled under the Controlled

Substances Act & can be misused & abused

• Respiratory depression is the most serious opioid AE • Can be immediately life-threatening

• Constipation is the most common long-term AE • Should be anticipated

For SaferUse: Know Drug Interactions, PK, & PD • CNS depressants* can potentiate sedation & respiratory

depression

• Some ER products rapidly release opioid (dose dump) when

exposed to alcohol

• Some drug levels may increase without dose dumping

• Use w/ MAOIs may increase respiratory depression • Certain opioids w/ MAOIs can cause serotonin syndrome • Can reduce efficacy of diuretics • Inducing release of antidiuretic hormone • Methadone & buprenorphine can prolong QTc interval • Drugs that inhibit or induce CYP enzymes can increase

or lower blood levels of some opioids

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Opioid Tolerant • Tolerance to sedating & respiratory-depressant effects is

critical to safe use of certain ER/LA opioid products, dosage unit strengths, or doses • Patients must be opioid tolerant before using • Any strength of transdermal fentanyl or hydromorphone ER • Certain strengths or daily doses of other ER products

• Opioid-tolerant patients are those taking at least • 60 mg oral morphine/day • 25 mcg transdermal fentanyl/hr • 30 mg oral oxycodone/day For 1 wk or longer • 8 mg oral hydromorphone/day • 25 mg oral oxymorphone/day • An equianalgesic dose of another opioid FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of lifethreatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf. 2012.

Key Instructions: ER/LA Opioids • Individually titrate to a dose that provides adequate

analgesia & minimizes adverse reactions

• Times required to reach steady-state plasma

concentrations are product specific

• Refer to product information for titration interval

• Continually reevaluate to assess maintenance of pain

control & emergence of AEs

Key Instructions: ER/LA Opioids • During chronic therapy, especially for non-cancer-related

pain, periodically reassess the continued need for opioids

• If pain increases, attempt to identify source, while adjusting

dose

• When an ER/LA opioid is no longer required, gradually

titrate dose downward to prevent signs & symptoms of withdrawal in physically dependent patients • Do not abruptly discontinue

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Common Drug Information This Class • Limitations of usage • Not for use as an as-needed analgesic • Not for mild pain or pain not expected to persist for an extended duration • Not for use in treating acute pain • Dosage reduction for hepatic or renal impairment • See individual drug PI • Relative potency to oral morphine • Intended as general guide • Follow conversion instructions in individual PI • Incomplete cross-tolerance & inter-patient variability require conservative dosing when converting from 1opioid to another • Halve calculated comparable dose & titrate new opioid as needed

S A T U R D A Y

Solid Oral Dosage Forms • Swallow tablets & capsules whole • Crushing, chewing, breaking, cutting or dissolving may result in rapid release & absorption of a potentially fatal opioid dose • Some capsules* can be opened & pellets sprinkled on applesauce for

patients who can reliably swallow without chewing & used immediately

• Exposure of some products to alcoholic beverages or

medications containing alcohol may result in rapid release & absorption of a potentially fatal opioid dose • Dispose of unused product at Drug-Take-Back Events • If not available, flush down toilet

*See individual PI

FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of lifethreatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf. 2012.

Transdermal Dosage Forms Do not cut, damage, chew, or swallow • Exertion or exposure to external heat can lead to fatal overdose • Monitor patients w/ fever for signs or symptoms of increased opioid

exposure

• Rotate location of application • Prepare skin: clip, not shave, hair, & wash area w/ water

Metal foil backings are not safe for use in MRIs • Dispose of unused product at Drug-Take-Back Events • If not available, flush down toilet • Butrans: seal in Patch-Disposal Unit & dispose of in trash

FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of life-threatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf. 2012.

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Drug Interactions Common to This Class • Concurrent use w/ other CNS depressants can increase

risk of respiratory depression, hypotension, profound sedation, or coma • Reduce initial dose of one or both agents

• Partial agonists & mixed agonist/antagonist analgesics†

may reduce analgesic effect or precipitate withdrawal

†Buprenorphine, pentazocine, nalbuphine, butorphanol

• Avoid concurrent use

• May enhance neuromuscular blocking action of skeletal

muscle relaxants & increase respiratory depression

• Concurrent use w/ anticholinergic medication increases

risk of urinary retention & severe constipation • May lead to paralytic ileus

Drug Information Common to This Class • Use in opioid-tolerant patients • See individual PI for which products: • Have strengths or total daily doses only for use in opioid-tolerant patients • Are only for use in opioid-tolerant patients at all strengths

• Contraindications • Significant respiratory depression • Acute or severe asthma in an unmonitored setting or in absence of resuscitative equipment • Known or suspected paralytic ileus • Hypersensitivity (eg, anaphylaxis) • See individual PI for additional contraindications

SPECIFIC DRUG INFORMATION FOR ER/LA OPIOID ANALGESIC PRODUCTS Unit VI

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Specific Characteristics • Know for ER/LA opioid products you prescribe: • Drug substance • Formulation

For detailed information, refer to online PI: DailyMed at www.dailymed.nlm.nih.gov Drugs@FDA at www.fda.gov/drugsatfda

• Strength

• Dosing interval

• Key instructions

• Specific information about conversion between products

where available

• Specific drug interactions

• Use in opioid-tolerant patients

• Product-specific safety concerns • Relative potency to morphine

S A T U R D A Y

Morphine Sulfate ER Capsules (Avinza)  Once a day  Initial dose in opioid non-tolerant patients is 30 mg  Titrate using a minimum of 3-d intervals  Swallow capsule whole (do not chew, crush, or dissolve) Key instructions  May open capsule & sprinkle pellets on applesauce for patients

Dosing interval

who can reliably swallow without chewing; use immediately

Drug interactions Opioid-tolerant

 MDD: 1600 mg (renal toxicity of excipient, fumaric acid)  Alcoholic beverages or medications w/ alcohol may result in rapid release & absorption of potentially fatal dose

 PGP inhibitors (eg, quinidine) may increase absorption/exposure of morphine by ~2-fold

 90 mg & 120 mg capsules for use in opioid-tolerant patients only

Product-specific  None safety concerns MDD=maximum daily dose; PGP= P-glycoprotein FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

BuprenorphineTransdermal System (Butrans) Dosing interval

 One transdermal system every 7 d  Initial dose in opioid non-tolerant patients on <30 mg morphine equivalents & in mild-moderate hepatic impairment: 5 mcg/h

 When converting from 30 mg-80 mg morphine equivalents, first taper to 30 mg morphine equivalent, then initiate w/ 10 mcg/h

 Titrate after a minimum of 72 h prior to dose adjustment  Maximum dose: 20 mcg/h due to risk of QTc prolongation  Application Key instructions • Apply only to sites indicated in PI • Apply to intact/non-irritated skin • Prep skin by clipping hair, wash site w/ water only • Rotate application site (min 3 wks before reapply to same site) • Do not cut  Avoid exposure to heat  Dispose of patches: fold adhesive side together & flush down toilet FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

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BuprenorphineTransdermal System (Butrans) Drug interactions

 CYP3A4 inhibitors may increase buprenorphine levels  CYP3A4 inducers may decrease buprenorphine levels  Benzodiazepines may increase respiratory depression  Class IA & III antiarrythmics, other potentially arrhythmogenic agents, may increase risk of QTc prolongation & torsade de pointe

Opioid-tolerant  10 mcg/h & 20 mcg/h for use in opioid-tolerant patients only Drug-specific safety concerns

 QTc prolongation & torsade de pointe  Hepatotoxicity  Application site skin reactions

Relative potency: oral morphine

 Equipotency to oral morphine not established

Methadone Hydrochloride Tablets (Dolophine) Dosing interval  Every 8 to 12 h

 Initial dose in opioid non-tolerant patients: 2.5 to 10 mg  Conversion of opioid-tolerant patients using equianalgesic tables can Key instructions

result in overdose & death. Use low doses according to table in full PI

 High inter-patient variability in absorption, metabolism, & relative analgesic potency

 Opioid detoxification or maintenance treatment only provided in a

federally certified opioid (addiction) treatment program (CFR, Title 42, Sec 8)

Drug interactions

 Pharmacokinetic drug-drug interactions w/ methadone are complex • CYP 450 inducers may decrease methadone levels • CYP 450 inhibitors may increase methadone levels • Anti-retroviral agents have mixed effects on methadone levels  Potentially arrhythmogenic agents may increase risk for QTc prolongation & torsade de pointe

 Benzodiazepines may increase respiratory depression FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

Methadone Hydrochloride Tablets (Dolophine) Opioidtolerant

 Refer to full PI

 QTc prolongation & torsade de pointe Drug-specific  Peak respiratory depression occurs later & persists longer safety than analgesic effect concerns  Clearance may increase during pregnancy  False-positive UDT possible Relative potency: oral  Varies depending on patient’s prior opioid experience morphine

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Fentanyl Transdermal System (Duragesic) Dosing interval  Every 72 h (3 d)  Use product-specific information for dose conversion from prior opioid  Hepatic or renal impairment: use 50% of dose if mild/moderate, avoid use if severe  Application • Apply to intact/non-irritated/non-irradiated skin on a flat surface Key • Prep skin by clipping hair, washing site w/ water only instructions • Rotate site of application • Titrate using no less than 72 h intervals • Do not cut  Avoid exposure to heat  Avoid accidental contact when holding or caring for children  Dispose of used/unused patches: fold adhesive side together & flush down toilet

S A T U R D A Y

Fentanyl Transdermal System (Duragesic) Specific contraindications:  Patients who are not opioid-tolerant  Management of Key instructions • Acute or intermittent pain, or patients who require opioid analgesia for a short period of time • Post-operative pain, out-patient, or day surgery • Mild pain  CYP3A4 inhibitors may increase fentanyl exposure Drug interactions  CYP3A4 inducers may decrease fentanyl exposure Opioid-tolerant  All doses indicated for opioid-tolerant patients only  Accidental exposure due to secondary exposure to unwashed/unclothed application site Drug-specific  Increased drug exposure w/ increased core body temp or fever safety concerns  Bradycardia  Application site skin reactions Relative  See individual PI for conversion recommendations from prior opioid potency: oral morphine FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

Morphine Sulfate ER-NaltrexoneTablets (Embeda)  Once a day or every 12 h  Initial dose as first opioid: 20 mg/0.8 mg  Titrate using a minimum of 3-d intervals  Swallow capsules whole (do not chew, crush, or dissolve)  Crushing or chewing will release morphine, possibly resulting in Key instructions

Dosing interval

fatal overdose, & naltrexone, possibly resulting in withdrawal symptoms

 May open capsule & sprinkle pellets on applesauce for patients who can reliably swallow without chewing, use immediately

Drug interactions Opioid-tolerant

 Alcoholic beverages or medications w/ alcohol may result in rapid release & absorption of potentially fatal dose

 PGP inhibitors (eg, quinidine) may increase absorption/exposure of morphine by ~2-fold

 100 mg/4 mg capsule for use in opioid-tolerant patients only

Product-specific  None safety concerns FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 8-28-2012. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

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Hydromorphone Hydrochloride ER Tablets (Exalgo) Dosing interval

 Once a day  Use conversion ratios in individual PI  Start patients w/ moderate hepatic impairment on 25% dose prescribed for patient w/ normal function

Key instructions

Drug interactions

Opioid-tolerant

 Renal impairment: start patients w/ moderate on 50% & patients w/ severe on 25% dose prescribed for patient w/ normal function

 Titrate using a minimum of 3 to 4 d intervals  Swallow tablets whole (do not chew, crush, or dissolve)  Do not use in patients w/ sulfite allergy (contains sodium metabisulfite)  None  All doses are indicated for opioid-tolerant patients only

Product-specific  Allergic manifestations to sulfite component adverse reactions Relative potency: oral morphine

 ~5:1 oral morphine to hydromorphone oral dose ratio, use conversion recommendations in individual product information

Morphine Sulfate ER Capsules (Kadian)  Once a day or every 12 h  PI recommends not using as first opioid  Titrate using minimum of 2-d intervals Key instructions  Swallow capsules whole (do not chew, crush, or dissolve)  May open capsule & sprinkle pellets on applesauce for patients who

Dosing interval

can reliably swallow without chewing, use immediately

 Alcoholic beverages or medications w/ alcohol may result in rapid Drug interactions

release & absorption of potentially fatal dose of morphine

 PGP inhibitors (eg, quinidine) may increase absorption/exposure of morphine by ~2-fold

Opioid-tolerant

 100 mg & 200 mg capsules for use in opioid-tolerant patients only

Product-specific  None safety concerns

Morphine Sulfate CR Tablets (MS Contin) Dosing interval  Every 8 h or every 12 h  Product information recommends not using as first opioid. Key  Titrate using a minimum of 2-d intervals instructions  Swallow tablets whole (do not chew, crush, or dissolve) Drug interactions

 PGP inhibitors (eg, quinidine) may increase

absorption/exposure of morphine by about 2-fold  100 mg & 200 mg tablet strengths for use in opioid-tolerant patients Opioid-tolerant only Productspecific safety  None concerns

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Tapentadol ER Tablets (Nucynta ER)  Every 12 h  50 mg every 12 h is initial dose in opioid non-tolerant patients  Titrate by 50 mg increments using minimum of 3-d intervals  MDD: 500 mg  Swallow tablets whole (do not chew, crush, or dissolve) Key instructions  Take 1 tablet at a time w/ enough water to ensure complete

Dosing interval

swallowing immediately after placing in mouth

Drug interactions

 Dose once/d in moderate hepatic impairment (100 mg/d max)  Avoid use in severe hepatic & renal impairment  Alcoholic beverages or medications w/ alcohol may result in rapid release & absorption of a potentially fatal dose of tapentadol

 Contraindicated in patients taking MAOIs Opioid-tolerant  No product-specific considerations Product-specific  Risk of serotonin syndrome safety concerns  Angioedema

Relative potency: oral morphine

 Equipotency to oral morphine has not been established

S A T U R D A Y

Oxymorphone Hydrochloride ER Tablets (Opana ER) Dosing interval

 Every 12 h dosing, some may benefit from asymmetric (different dose given in AM than in PM) dosing

 Use 5 mg every 12 h as initial dose in opioid non-tolerant patients & patients w/ mild hepatic impairment & renal impairment (creatinine clearance <50 mL/min) & patients >65 yrs

Key instructions

 Swallow tablets whole (do not chew, crush, or dissolve)  Take 1 tablet at a time, w/ enough water to ensure complete swallowing immediately after placing in mouth

 Titrate using a minimum of 2-d intervals  Contraindicated in moderate & severe hepatic impairment Drug interactions

Opioid-tolerant

 Alcoholic beverages or medications w/ alcohol may result in absorption of a potentially fatal dose of oxymorphone

 No product-specific considerations

Product-specific  None safety concerns Relative potency: oral morphine

 Approximately 3:1 oral morphine to oxymorphone oral dose ratio

Oxycodone Hydrochloride CR Tablets (OxyContin) Dosing interval

Key instructions

 Every 12 h  Opioid-naïve patients: initiate treatment w/ 10 mg every 12 h  Titrate using a minimum of 1 to 2 d intervals  Hepatic impairment: start w/ ⅓‐½ usual dosage  Renal impairment (creatinine clearance <60 mL/min): start w/ ½ usual dosage

 Consider other analgesics in patients w/ difficulty swallowing or

underlying GI disorders that predispose to obstruction. Swallow tablets whole (do not chew, crush, or dissolve)  Take 1 tablet at a time, w/ enough water to ensure complete swallowing immediately after placing in mouth  CYP3A4 inhibitors may increase oxycodone exposure Drug interactions  CYP3A4 inducers may decrease oxycodone exposure  Single dose >40 mg or total daily dose >80 mg for use in opioidOpioid-tolerant tolerant patients only  Choking, gagging, regurgitation, tablets stuck in throat, difficulty Product-specific swallowing tablet safety concerns  Contraindicated in patients w/ GI obstruction Relative potency: oral morphine

 Approximately 2:1 oral morphine to oxycodone oral dose ratio

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Summary • Prescription opioid abuse & overdose is a national epidemic • Clinicians must play a role in prevention • Understand how to assess patients for treatment w/ ER/LA opioids • Be familiar w/ how to initiate therapy, modify dose, & discontinue use of ER/LA opioids • Know how to manage ongoing therapy w/ ER/LA opioids • Know how to counsel patients & caregivers about the safe use of ER/LA opioids, including proper storage & disposal • Be familiar w/ general & product-specific drug information concerning ER/LA opioids

Thank you for completing the post-activity assessment for this CO*RE session. Your participation in this assessment allows CO*RE to report de-identified numbers to the FDA. A strong show of engagement will demonstrate that clinicians have voluntarily taken this important education and are committed to patient safety and improved outcomes. Thank you!

Thank You!

www.core-rems.org

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S A T U R D A Y

May 3-5 â&#x20AC;˘ San Francisco

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Session #5: Saturday, May 4, 2013 | 2:00-2:30 pm

HIV Prevention and Screening (Mark Carmichael)

Marshall Kubota, MD

Activity Description This session is the first of three in a 3x30 block – quick updates on topics of importance to family physicians. Dr. Kubota will discuss HIV and introduce one of CAFP’s newest national projects. Learning Objectives At the end of this educational activity participants should be able to: - Apply recommendations and procedures for primary care practice treatment teams to participate in HIV care. - Demonstrate effective, culturally competent and patient-centered communication skills to encourage patient adherence to testing and treatment. Marshall Kubota, MD is currently the regional medical director for Partnership Health Plan, in Sonoma County. He completed his medical degree at St. Louis University School of Medicine and did his residency at Sutter Medical Center of Santa Rosa. Dr. Kubota has served as residency director at the program and medical director for both the North Coast Area AIDS Education and Training Center and Public Health Clinical Services for Sonoma Department of Health Services. He is the found of the Sonoma County Center for HIV Prevention and Care. Faculty Disclosure: Dr. Kubota declares that in the past 12 months he has received honoraria from ViiV and Gilead Sciences, both makers of HIV therapeutic options. In compliance with its policy for Conflict of Interest identification, management and resolution, the CAFP’s Committee on Continuing Professional Development reviewed and approved this session. This session is supported by unrestricted educational grants from Gilead.

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Family Medicine and HIV: Improving Screening, Testing and Treatment

S A T U R D A Y

2013| California Academy of Family Physicians

Today’s Faculty Marshall Kubota, MD Clinical Professor Department of Family and Community Medicine University of California, San Francisco

Disclosure and Industry Support 

The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP.



It is the policy of CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all of their continuing education activities.



Dr. Kubota declares that in the past 12 months he has received honoraria from ViiV and Gilead Sciences, both makers of HIV therapeutic options.



This activity is supported by unrestricted educational grants from Gilead.

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Learning Objectives    

Screen patients for HIV, especially identifying “at risk” populations Advocate for HIV testing of all patients age 13-64 who have not previously been tested and annual testing of high-risk patients. Describe strategies to improve patient adherence Treat to the highest confidence level

Screening • We are still missing the boat…

The Dire Facts •

1.2 million people living with HIV in the United States today ▫

50% are not under a physician’s/medical team’s care 

Of that 50%, 60% have been diagnosed and know they are HIV positive ▫

40% remain undiagnosed

CDC, 2011

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Increasing Prevalence •

Estimated 56,000 new infections occurring each year in the US

•

Fewer deaths from HIV/AIDS, leading to increased prevalence

•

Significant racial, economic, and gender disparities… ▫

In infection rates, morbidity, and mortality

CDC, 2011

S A T U R D A Y

Increasing Prevalence

Primary Care Centers for Disease Control

“HIV screening is part of an overall public health strategy of intervention in primary care.”

Cheryl Modica, PhD, MPH, BSN

“Screening for HIV should be as routine as testing for cholesterol and blood sugar.”

Centers for Disease Control Prevention. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. MMWR.52(RR12):1-24. Modica C. Integrating HIV screening into routine primary care: a health center model. Presentation at National Association of Community Health Centers Meeting; January 14, 2009; Philadelphia

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The Barriers: Stigma • Thirty years into the HIV/AIDS epidemic, substantial shares of Americans continue to express discomfort at the idea of interacting with people living with HIV. • 45% of Americans would be uncomfortable having their food prepared by someone who is HIV‐positive. • 29% uncomfortable having their child in a classroom with an HIV‐positive teacher. • 18% uncomfortable working with someone with HIV.

HIV/AIDS at 30, A public opinion survey The 2011 Survey of Americans on HIV/AIDS was designed and analyzed by public opinion researchers at the Kaiser Family Foundation. The survey was conducted April 4-May 1, 2011, among a nationally representative random sample of 2,583 adults ages 18 and older.

USPHS • Recommends screening all pregnant women for HIV. • Recommends screening for HIV all adolescents and adults at increased risk for HIV infection: ▫ ▫ ▫ ▫ ▫

MSM unprotected sex with multiple partners injection drug use exchange sex for money or drugs or have sex partners who do HIV infected sex partners, bisexual, or injection drug users

U.S. Preventive Services Task Force (USPSTF)

Institute of Medicine • Effective sexual histories can help identify those at greater risk • Majority of providers receive little training or practical experience in HIV care. . . many of them may be uncomfortable taking sexual histories (IOM)

IOM. HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care. Released: March 17, 2011.

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Testing

S A T U R D A Y

We need to do better •

A 2009 survey of primary care physicians found that only 17% routinely screen their patients for HIV. (CDC, 2011)

•

Nearly 50% of adults who have been tested say they have to ask their doctor for an HIV test.(Kaiser Family Foundation, June 2011)

•

The Second Annual Health HIV State of HIV Primary Care survey: ▫

Nearly 50% of primary care providers do not provide routine HIV testing to patients

▫

20% of HIV Treatment Providers do not routinely test all their patients for HIV

Testing •

More than 50% of HIV treatment providers who test, routinely cite patient resistance to testing as the biggest barrier. ▫

“Stigma” was perceived to be the largest patient barrier.

The Second Annual HealthHIV State of HIV Primary Care survey (with 1,806 U.S.based respondents between July 20 and October 28, 2011)

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CDC Recommendations • CDC recommends HIV testing for all patients between the ages of 13-64 as a routine part of medical care at least once in their lives – regardless of perceived risk for the disease. • CDC recommends individuals at high risk be tested at least annually. • These recommendations put primary care on the frontline of HIV screening. • Opt-out approach

Who’s At Risk ? • HIV/AIDS is an example of profound healthcare disparity in the US. ▫ Black/African Americans have:  significantly higher undiagnosed HIV infections  significantly higher HIV/AIDS mortality burden: 782% greater among blacks than among whites.(AHRQ)

▫ Poverty is a major driver of HIV infection ▫ Significant gender differences

Number and Rate of Persons ≥ 13 Years of Age Estimated to Have Undiagnosed HIV Infection Race/Ethnicity and Sex

Number

White

72,000

Male

62,800

Female

Rate Per 100,000 Population

42.2 75.6

9200

10.5

113,100

380.3

Male

77,500

556.5

Female

35,700

225.7

Hispanic/Latino

41,900

126.4

Male

34,700

201.6

7200

45.2

Black/African American

Female

Agency for Healthcare Research and Quality. National Healthcare Disparities Report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; December 2006. AHRQ Pub. No. 07-0012

CDC Recommendation 

Individuals at high risk be tested at least annually.



Persons (or their sex partners) who have had more than one sex partner since their most recent HIV test as high risk.



According to the CDC, 28% of patients who are considered at high risk for contracting the virus, have never been tested.

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Adherence “The most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is non-adherence, a primary care problem if ever there was one.” – Dr. Mitchell Katz, Director Los Angeles Department of Health Services

Katz, M. (2011). Human immunodeficiency virus is (once again) a primary care disease. Arch Intern Med, ;171:719-20

S A T U R D A Y

Adherence • Ensure clinicians understand the benefits of a more engaged, active patient; • Ensure clinicians have the tools and resources to successfully communication, in a culturally-competent manner, with the patient and engage them in their care; and • Provide clinicians with the data and resources to understand why shared decision-making leads to more successful outcomes for patients.

Prevention Combating Stigma/Fear with Education • Effective prevention counseling is needed: ▫ High risk behaviors  Unprotected sex  Injection drug users •

HIV treatment as prevention ▫ ▫

Post-exposure prophylaxis (PEP) Pre-exposure prophylaxis (PrEP)

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Early Diagnosis According to the CDC: • “A substantial number of primary care physicians are missing important opportunities to prevent HIV transmission by not adequately assessing patients’ risks and not providing necessary risk-reduction counseling during their physician—patient encounters.” • Approximately one-third of people are getting diagnosed with HIV after they have a complication of AIDS or advanced HIV-related immunodeficiency. CDC, 2011

Linked to Care • National HIV/AIDS Strategy (NHAS) challenge: ▫ increase the proportion of patients linked to care within 3 months of their HIV diagnosis from 65% to 85% by 2015. • Only 45% of HIV-positive patients in the US are receiving regular medical monitoring1 • One-third of patients are not being linked with specialist HIV care within the first year of their diagnosis with the infection. 1 1Hall

HI et al. Retention in care of adults and adolescents living with HIV in 13 U. S. areas. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0b013e318249fe90, 2012

Treat to Highest Level of Competence

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Institute of Medicine “There are not enough new physicians entering the specialty to address the needs of the growing number of Americans living with HIV/AIDS.”

IOM. HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care. Released: March 17, 2011.

S A T U R D A Y

Co-Management • A generation of HIV providers will retire in the next 5-10 years • Newer clinicians don’t have the depth of experience with seriously ill HIV + patients • Use of medical home model may reduce the number of HIV specialty clinics providing comprehensive care • Uncertainty of Ryan White funding may force realignment of care into primary care/community health center models

Aging Population • By 2015, half of Americans living with HIV will be older than 50. • More HIV patients developing co-morbid diseases that come with older age. • More HIV complications to address: mental illness, substance abuse, cardiovascular disease, etc.

IOM. HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care. Released: March 17, 2011

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Co-Morbidities According to Jens Lundgren, MD, DMSc: “The contemporary challenge in HIV medicine is no longer to suppress the virus but actually to maintain health of patients with HIV, and the major focus now and the dominating reason for why people are still getting sick, even for those who are in care, is the development of various comorbidities.” “HIV physicians are great in treating the virus but may not have the skill set necessarily to deal with the prevention and treatment of the comorbidities.” Jens Lundgren, MD, DMSc, professor in the Department of International Health, Immunology and Microbiology at the University of Copenhagen, Denmark, director of the Copenhagen HIV Program in Denmark

Treatment “PCPs are not always aware of the benefits and risks associated with initiating antiretroviral therapy (ART) in patients, based on CD4 cell count as well as other individual patient factors.”

Bartlett, J., & Lane et al, H. (2011). Panel on Antiretroviral Guidelines for Adult and Adolescents. Washington DC: Department of Health and Human Services.

Treatment Guidelines • International Association of Physicians in AIDS Care (IAPAC) has just developed evidence-based guidelines to improve ART initiation, retention, and adherence (March, 2012) • Department of Health and Human Services (DHHS) published guidelines (January, 2011) • International AIDS Society-USA (IAS-USA) published guidelines (July, 2010)

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The Carmichaels • Anyone at risk?

S A T U R D A Y

Thank You

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Session #6: Saturday, May 4, 2013 | 2:30-3:00 pm

Hep C: Asking the Right Questions (Chris Lee)

George Kent, MD

Activity Description This session is the second of three in a 3x30 block â&#x20AC;&#x201C; quick updates on topics of importance to family physicians. Dr. Kent will discuss Hep C and provide look at screening techniques for family physicians Learning Objectives At the end of this educational activity participants should be able to: - Identify strategies for overcoming barriers to testing for HCV - Provide appropriate initial and follow up tests for HCV - More effectively communicate with patients regarding HCV George Kent, MD, completed his medical degree at Case Western Reserve University School of Medicine and completed a preventive medicine residency at the Centers for Disease Control. He also completed a residency at University of California, San Francisco Community Hospital of Sonoma County. Because of his fluency in Spanish, he has volunteered for international projects to provide medical care or to train health professionals in rural Mexico and Central Mexico, consulted with the Republic of Panama on STDs and HIV prevention, and co-translated a health care manual for rural care workers. Locally, Dr. Kent has conducted grand rounds on a breadth of primary care topics such as immunizations, antibiotic resistance, women and AIDS, hepatitis, TB and immigrant care. Dr. Kent has authored papers on SDTs, public health and the water supply, hurricane and ER visits, and acupuncture-associated Hep B. In addition to his academic appointment in Family and Community Medicine at Stanford, he serves as Medical Director of the Oâ&#x20AC;&#x2122;Connor-San Jose Family Health Center. Faculty Disclosure: Dr. Kent declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

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CAFP | Committee on Continuing Professional Development | CMe‐Spotlight Issue #2 | 12‐2012

Author: George Kent, MD

When was the last time you diagnosed adult Hepatitis C?

CDC is recommending that everyone born during 1945 through 1965, also known as “Baby Boomers,” get a blood test for Hepatitis C. This recommendation calls for one‐time testing of this birth cohort.

This Hepatitis C testing recommendation was made because:

1. There are high rates of Hepatitis C in people born during 1945‐1965. People born during 1945 through 1965 are 5 times more likely than other adults to be infected. In fact, 75% of adults with Hepatitis C were born in these years. The major risk factors for Hepatitis C infection include receiving a blood transfusion before 1992, receiving clotting factor concentrates before 1987, injection drug use, and prolonged hemodialysis. 2. Testing can help prevent deaths from Hepatitis C. The numbers of people who will develop serious health problems and die from Hepatitis C are expected to rise rapidly in the coming years. Early diagnosis and treatment can help prevent liver damage, cirrhosis, and liver cancer. It is estimated that one‐time testing of everyone born during 1945 through 1965 will prevent more than 120,000 deaths. 3. There is a lack of awareness. Many people with Hepatitis C do not know that they are infected. One‐time testing of everyone born during 1945 through 1965 would find an estimated 800,000 undiagnosed Hepatitis C cases. 4. There have been recent advances in treatment. Two new medications, the protease inhibitors telapravir and bocepravir, are now available. When added to the standard treatment of peginterferon and ribavirin, triple therapy can increase the effectiveness and shorten treatment time for many people. Successful treatment is defined as a negative HCV RNA test 6 months after completing treatment. This is referred to as a sustained viral response or SVR. SVR rates for genotype 1 HCV infection, the most common genotype in the US, were around 40‐50% without triple therapy; the addition of a protease inhibitor has increased SVR rates up to 70‐80%. However, response rates among African Americans are lower (approximately 40‐50%), but are higher than those seen with peginterferon and ribavirin alone (approximately 10‐30%). What test should be ordered to screen for hepatitis C? • Hepatitis C antibody A positive antibody test indicates prior or current infection with Hepatitis C. It does NOT indicate immunity; in fact, only about 15‐20% of those with positive Hepatitis C antibody have cleared the virus—the remainder are chronically infected. Those with a positive test should receive further testing to determine whether they have active infection. What follow‐up test should be ordered if the Hepatitis C antibody test is positive? • HCV RNA test (either qualitative or quantitative)—this test indicates if there is Hepatitis C virus in the blood. If the test is positive, the patient should be referred for treatment. May 3-5 • San Francisco

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Key counseling points:  Those with ongoing risk behaviors (e.g., injection drug use), should be retested periodically  Those with positive HCV RNA (active infection), should be advised: o ‐Abstain from alcohol o ‐Avoid new medications, including OTC and herbal medications, without consulting their health care provider o ‐To minimize transmission to others, do not donate blood, tissue, or semen o ‐Do not share appliances that might come into contact with blood, such as razors, toothbrushes, and nail clippers  Those with positive HCV RNA should be immunized against Hepatitis A and B, if susceptible, to prevent further liver injury (test for immunity with anti‐HAV and anti‐HBs)  Recommend testing for HIV infection as well Resources for patient education: http://www.cdc.gov/knowmorehepatitis/Media/PDFs/FactSheet‐Boomers.pdf http://www.cdc.gov/features/HepatitisCTesting/index.html Resources for health care professionals: http://www.cdc.gov/hepatitis/HCV/index.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm?s_cid=rr6104a1_w

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Session #7: Saturday, May 4, 2013 | 3:00-3:30 pm

Tips for TBI Screening (Anthony Jones)

Lee Ralph, MD

Activity Description This session is the third of three in a 3x30 block – quick updates on topics of importance to family physicians. Head injuries and resulting TBIs are on the rise, and Dr. Ralph will provide tools to help family physicians address these issues with patients. Learning Objectives At the end of this educational activity participants should be able to: - Complete a self-assessment on baseline questions re: consensus guidelines, CIF guidelines, prevalence in their practices, referral patterns, need for additional assistance in managing head injured patients, use of head injury patient instruction sheets Dr. Ralph joined San Diego Sports Medicine after serving as a family physician at UCSD’s Family Practice and Preventive Medicine Department. He graduated from Amherst College and the University of Virginia School of Medicine. Dr. Ralph is currently an Assistant Clinical Professor at the UCSD School of Medicine and is Board Certified in Family Practice and Sports Medicine. Dr. Ralph is the past president of the San Diego Academy of Family Physicians. Dr. Ralph has been voted among San Diego “Top Doctors” in Family Medicine for the past six years and in 2008, 2009, and 2010 he was also voted as a “Top Doctor” in Sports Medicine. Dr. Ralph, a member of CAFP’s Committee on Continuing Professional Development, also serves on the CAFP’s Board of Directors and will be installed as Vice Speaker of the All Member Advocacy Meeting on Saturday morning.

S A T U R D A Y

Faculty Disclosure: Dr. Ralph declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

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Tips for TBI Screening Lee P. Ralph, MD San Diego Sports Medicine and Family Health Center CAFP 2013 Annual Scientific Assembly

Faculty Lee Ralph, MD – San Diego Sports Medicine and Family Health Center – Assistant Clinical Professor at the UCSD School of Medicine and is Board Certified in Family Practice and Sports Medicine – Member, CAFP’s Committee on Continuing Professional Development

• Dr. Ralph declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

Learning Objectives • Recognize the signs and symptoms associated with concussions • Demonstrate knowledge of assessment tools for diagnosing mTBI/concussions • Apply an appropriate return to play or school decision making process for concussed patients

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Tips for TBI Screening • Tip #1: “The eye can not see what the mind does not know”. • Tip #2: “It is difficult to treat what you have not diagnosed”.

S A T U R D A Y

The Carmichael Family

CAFP Annual Scientific Assembly 2013

The Jones Family

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Anthony Jones • Anthony Jones: 34 yo former college football player, now high school teacher and football coach. • Married with 2 young children, Janae age 10 and Sean age 8.

CAFP Annual Scientific Assembly 2013

Anthony Jones • Generally in good health • Suffered 2 known concussions in college playing football, one with LOC < 30 seconds. • Concerned about recent headaches and occasional “forgetfulness” at times. • Lots of information about concussions and future risk of dementia on internet. CAFP Annual Scientific Assembly 2013

Anthony Jones • Also concerned about Janae and Sean. Both are active athletically playing competitive soccer and football, respectively. • Wife, Sarah is also concerned and has been hearing alot about the dangers of concussions in these sports. • Should they be concerned? CAFP Annual Scientific Assembly 2013

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Question • Would you allow your son, grandson, nephew to play tackle football?

S A T U R D A Y

Question • Would you allow your daughter, granddaughter, niece to play competitive youth soccer?

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Recent Developments • • • •

Psychological Issues Chronic Traumatic Encephalopathy New State Laws and Regulations Research using neurocognitive tests

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S A T U R D A Y Definition • Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces • May be caused by a direct blow to the head, face, neck or body with an “impulsive” force transmitted to the head • Results in rapid onset of short –lived impairment of neurologic function that resolves spontaneously 4th International conference on concussion in sport, Zurich, Nov. 2012

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Definition • Symptoms largely reflect a functional disturbance rather than a structural injury • May or may not involve loss of consciousness • Resolution of symptoms typically follows a sequential course but in some cases symptoms may be prolonged • No abnormality on standard structural neuroimaging studies 4th International Conference on concussion in sport, Zurich, Nov. 2012

Signs and Symptoms of Acute Concussion • • • •

Physical Cognitive Emotional Sleep Related

4th International Conference on concussion in sport, Zurich, Nov. 2012

Physical Signs and Symptoms of Acute Concussion • • • • • • •

Headache Nausea/vomiting Balance problems Visual problems Fatigue Sensitivity to light or noise “Dazed” or “Stunned” US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

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Cognitive Signs and Symptoms of Acute Concussion • • • • • •

Feeling mentally “foggy” or slowed down Difficulty concentrating or remembering Forgetful of recent information (amnesia) Confused about recent events Answers questions slowly Repeats questions(perseverates)

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

S A T U R D A Y

Emotional Signs and Symptoms of Acute Concussion • • • • •

Irritability Sadness Hyper‐emotional Nervousness Anxiety

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

Sleep Related Signs and Symptoms of Acute Concussion • Drowsiness • Hyper‐ or Hyposomnolence • Difficulty falling asleep

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

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Office Tools and Techniques for Evaluation • Thorough history: signs, symptoms, previous head injuries • Head and neck exam • Focused neurological exam(including mental status, gait and balance assessment) –Balance Error Scoring System(BESS) • SAC(Standardized Assessment of Concussion) or SCAT3(Sport Concussion Assessment Tool)/ Child‐SCAT3(ages 5‐12)

Symptom Checklist

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S A T U R D A Y

Return to Play

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Concussion Injury Advice

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SCAT3 Balance Examination • • • •

Double leg stance Single leg stance Tandem stance Error types 1. 2. 3. 4. 5. 6.

Hands lifted off iliac crest Opening eyes Step, stumble or fall Moving hip into >30 degrees abduction Lifting forefoot or heel Remaining out of test position for > 5 seconds

NCAA.ORG has the BESS and SCAT3 demonstration video

S A T U R D A Y

Prevention • • • •

Headgear ‐ “risk compensation” Mouth guards Rule Changes Education – public, players, athletic trainers, coaches, parents

Neuropsychological Testing • Measures reaction time, memory and other neurocognitive functions • Useful because cognitive recovery will usually be delayed until after clinical symptom resolution • Can assist with return to play clinical decision making • Done when the athlete is asymptomatic • Can be used for pre‐participation screening with high risk sports

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Treatment • • • •

Rest Rest More rest – both physical and cognitive Education – patients/players, coaches, parents and teachers • Most concussions resolve(80‐90%) within a relatively short time period(7‐10 days)

What Happened ?

Chronic Traumatic Brain Injury • Post‐Concussion Syndrome – small number usually 10‐20% of all concussions • Second Impact Syndrome(SIS) ‐ controversial • Chronic Traumatic Encephalopathy(CTE) – NFL Football Brain Registry – also referred to as “dementia pugilistica”, some cases can mimic ALS • Long term psychiatric effects – much more significant than previously believed

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Research • “Some people may be genetically more sensitive to head impacts.” (Neurology, 5/16/12) • “Young athletes lack perception of cognitive deficits compared to somatic symptoms.” (Applied Neuropsychology: Child, 4/12) • “Young male athletes feel “more recovered” quicker than female athletes.” (UPMC Center for Sports Medicine Concussion Program)

S A T U R D A Y

Question • Would you allow your son, grandson, nephew to play tackle football?

Question • Would you allow your daughter, granddaughter, niece to play competitive youth soccer?

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Youth Soccer • Girls soccer has the 2nd highest rate of reported concussions in young athletes (American Journal of Sports Medicine, April 2012, Vol.40) • Prevalence of TBI’s in high school sports: – Football: 0.47/1000 athlete exposures – Girls soccer: 0.36/1000 athlete exposures ( Data from CDC)

Summary • MTBI/Concussions are a common everyday occurrence frequently seen by primary care providers – “Take it seriously...bruising the brain is a big deal” (Dr. Dave Baron 1/5/11) • Guidelines and tools are available to help in the management of these cases • There is a tremendous need to improve our knowledge base and understanding of these injuries • Whenever possible...“Play it safer” CAFP Annual Scientific Assembly 2011

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Session #8: Saturday, May 4, 2013 | 4:00-4:30 pm

Busting Autism Myths (Conner and Ethan Carmichael-Perez)

David Schneider, MD Activity Description This session is the first of three in a 3x30 block – quick updates on topics of importance to family physicians. The myths about autism are front page news and Dr. Schneider will debunk many of them for you. Learning Objectives At the end of this educational activity participants should be able to: - Identify and use a routine screening tool for autism - Identify and accurately respond to at least one common myth about autism - Identify at least one intervention (or referral) to assist in management of autistic patients. Dr. Schneider cares for the underserved in Santa Rosa, CA, serving Latino, Southeast Asian, and Eritrean populations. His professional interests include the doctor-patient relationship, clinical skills, and teaching the breadth and depth of family medicine for more than 18 years. Cardiovascular system conditions are one of his specialty topics, and he points to the growing body of evidence suggesting that lifestyle is as effective as, or more effective than, pharmacologic interventions in primary prevention. He also focuses on conditions of the endocrine system (especially thyroid), skin and dermatology, primary prevention focusing on lifestyle, and procedures. He produces Dr. Dave’s To Your Health segments for Wine Country Radio and BlogTalkRadio.com. Faculty Disclosure: Dr. Schneider declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

May 3-5 • San Francisco

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David M. Schneider, MD Faculty Physician/Didactics Director, Santa Rosa Family Medicine Residency Associate Clinical Professor of Family and Community Medicine, UCSF Dr. Schneider declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

   

Identify and use a screening tool for autism. Identify and respond to at least 1 myth about autism. Identify at least 1 intervention to assist in management of autistic patients. Lots more.

VIVIAN CARMICHAEL AND MARTA PÉREZ (MARRIED)

ETHAN AND CONNER CARMICHAEL‐PÉREZ

Ethan (4 yo)

Conner (18 mo)

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ETHAN (4 YO): DX AUTISM

CONNER (18 MO): NO SIGNS OF AUTISM

Connor and Ethan are biologic brothers, and were adopted together by Vivian and Marta



“Autism” is a disease.

 

Myth Fact



“Autism” is a disease.



Myth

May 3-5 • San Francisco

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

Many people and epidemiologists say “autism,” when they actually mean the aggregate of Autism Spectrum Disorders (ASDs).



Therefore, people say “autism” when they are referring to an aggregate of several conditions.



Heterogeneous group of neurodevelopmental disorders.  Diverse & unclear etiologies.  Constellations of symptoms w/impairments in

reciprocal social interaction, communication, and behavior (restricted & repetitive or stereotyped interests and activities).

DSM-4-TR; Pediatrics 2007;120:1183-1215



Higher cognitive function, more able to reliably express themselves, more interest in interpersonal activity.  No significant language delay (may be subtle signs).  No clinically significant cognitive delay.  No clinically significant delay in learning skills and

adaptive behaviors.  Hallmark: atypical social development + extreme

behavioral rigidity. DSM-4-TR

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

There is an epidemic of autism (or ASDs).



Myth Fact



There is an epidemic of autism (or ASDs).



Myth (mostly)



“Epidemic” refers to infectious diseases. More ASDs are being diagnosed:



S A T U R D A Y

  recognition?  More toxins causing genetic or epigenetic

phenomena?  Diagnosing ASDs and not just autism?  Something else?

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 

1966‐1997: 1/472 ‐ 1/3333. 1997‐2003: 1/121 ‐ 1/1923.  One Swedish study in 1999 found 1/83 – no other

study used the same diagnostic criteria. 

What happened in 1997?  Diagnostic criteria changed to DSM‐4 or ICD‐10.

Arch Dis Child 2006;91:8–15

Study Date

Autism Prev

Total ASD/PDD Prev

2001

1/1595

1/160

2001

1/250

1/149

2003

‐‐‐‐‐

1991 =1/3333  2002 = 1/192 (17X )

2006

1/257

1/86

2006

‐‐‐‐‐

1/294 – 1/149

2008

1/463

1/196

2009

1/500

1/143 – 1/160

2011

‐‐‐‐‐

1996 = 1/5587  2005 = 1/348 (16X )

2012

‐‐‐‐‐

2002 = 1/156  2008 = 1/88

2012

‐‐‐‐‐

1/143

JAMA 2001;285:3093-9; Pediatrics 2001;108:1155-61; ArchPediAdolesMed 2003;157:622-7; Lancet 2006;368:210-5; MMWR 2006;55:481-6; DevMedChildNeuro 2008;50:672-7; PediRes 2009;65:591-8; JChildNeuro 2011;26:830-4; MMWRSurveillSumm 2012;61:1-19; Pediatrics 2012;130:e152-8



Several studies suggest or show that at least part, or much, of the increase is due to broader diagnostic criteria and/or more awareness by providers and the public. There remains the possibility that other factors are increasing the prevalence of autism.

ActaPaediatr 2005;94:2-15; PediatrRes 2009;65:591-8; ArchDisChild 2006;91:8-15; MentRetardDevDisabilResRev 2002;8:151-61; Pediatrics 2006;117:1028-37; JIntellectDisabilRes 2005;49:231-8; ArchPediatrAdolescMed 2005;159:37-44

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

Vivian and Marta ask you if they somehow caused Ethan’s autism. They heard that autism can be due to “refrigerator moms” who are emotionally distant. They are a lesbian couple who love each other and believe they have shown appropriate love to their adopted children, but a (heterosexual) friend has made them wonder.



Autism results, at least in part, from parents (esp...... mothers) who do not love their children, or who do not show their love.



Myth Fact



Autism results, at least in part, from parents (esp...... mothers) who do not love their children, or who do not show their love.



Myth

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

Many people believe autism is a purely psychological condition like depression, anxiety.  Gee, I thought they weren’t “purely psychological”

either. 

“A lie gets halfway around the world before the truth has a chance to get its pants on.” – Winston Churchill



1949: Kanner suggests autism d/t "genuine lack of maternal warmth,” children exposed from "the beginning to parental coldness, obsessiveness, and a mechanical type of attention to material needs only.... Their withdrawal seems to be an act of turning away from such a situation to seek comfort in solitude.” AmJOrthopsychiatry 1949;19:416–26



1950s: Bruno Bettelheim (U of Chicago professor) champions theory that children of cold, distant mothers do not bond properly and develop autism. 1960: Kanner agrees publicly.

TIME 1960, July 25; http://en.wikipedia.org/wiki/Refrigerator_mother_theory

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

1964: Bernard Rimland (psychology researcher w/autistic son) suggests neurologic cause in Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behavior.  Kanner wrote the foreword of the book.  Unfortunately, Dr Rimland also believed that

immunizations and/or thimerosal caused autism.



“Every man is wise when attacked by a mad dog…only the wisest survive when attacked by a mad notion.” ‐‐Robertson Davies



The pathogenesis of autism is still poorly understood, and it appears to be multifactorial.

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

Complex genetic etiologic factors.  4:1 male predominance.  High concordance in monozygotic twins (58‐92%),    

less in dizygotic (0‐36%). Multiple genes. Variable expression. Not just single gene or X‐linked. Epigenetic factors—genes turned on/off early in development (heritable!!).

DSM-4-TR; JAMA 2003;289:87-9; MMWR Surveill Summ 2007;56:12-28; PsycholMed 1995;25:63-77; ChildPsycholPsychiatry 1977;18:297-321; ArchPediatrAdolesc Med 2009;163:907-14; ArchGenPsychiatry 2011;68:1095-1102; NatRevGenet 2001;2:943-55; JChildPsycholPsychiatry 1989;30:405-16; Pediatrics 2004;113:e472-86; AmJMedGenet C SeminMedGenet 2006;142C(1):13-23; JAbnormChildPsychol 2000;28:3-14; HumMolGenet 2004;13:629-39; ClinGenet 2006;69:21-2; ArchGenPsych 2011;68:1095-102; PsycholMed 1995;25:63-77



Neurobiologic factors.   brain size (2‐10%) & HC during infancy. ▪ Did you know that 25% of children with autism spectrum disorders have HC > 97th %ile, and that  rate of head growth occurs in up to 70% of children with autism during 1st yr of life?  Poss frontal/prefrontal cortex diffs in

neuroanatomy and connectivity.

Lancet 1993;341:1225-6; JAmAcadChildAdolescPsychiatry 1997;36:282-90; JAMA 2003;290:337-44; JChildNeurol 2007;22:1182-90; Am J Med Genet C Semin Med Genet 2006;142C(1):33-9; AmJ Psychiatry 1995;152:1145-9; JAmAcadChildAdolescPsychiatry 1996;35:530-6; JAMA 2011;306:2001-10



Possibly differences in regional serotonin synthesis in brain – may lead to “miswiring of the neural circuits specifying hemispheric specialization.” Neurologically‐based differences in speech processing.

IntJDevNeurosci 2005;23:171-82; PNAS USA 2003;100:5567-72; ClinNeurophysiol 2005;116:1655-64; JChildPsycholPsychiatr 2004;45:1107-14; BrainResCognBrainRes 2005;23:221-34

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

Environmental factors.  Uncertain significance.  May depend on timing (incl perinatal), duration,

intensity of exposure.  May be a “2nd hit” to predisposed infants/children. 

Advanced parental age – mother or father (≥35)   autism risk.

Pediatrics 2011;128:344-55; Pediatrics 2012;129:e1121-8; Pediatrics 2007;120:1183-1215; Pediatrics 2004;113:e472-86; EnvironHealthPerspect 2007;115:1482-9; ArchGenPsychiat 2006;63:1026-32; Arch PediatrAdolescMed 2007;161:334-40; BrJPsychiat 2009;195:7-14; AmJEpidem 2009;170:1118-26; AmJ Epidem 2008;168:1268-76; PediatrNeurol 2010;43:300-2; JAmAcadChildAdolescPsychiatr 2012;51:477-86

S A T U R D A Y

There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy. …and immunizations are NOT one of them (in this case)!



“It is a riddle wrapped in a mystery inside an enigma.” ‐‐Winston Churchill, referring to Russia in 1939



“Autism makes WW2‐era Russia look like a 4‐ piece jigsaw puzzle.” ‐‐Dr Dave Schneider, 2013

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

Maternal exposure to childhood abuse is associated w/increased risk of autism in her children—RR = 3.0. If grandpa was >50 when he had his child, his grandchild has  risk (RR = 1.79 for grandpa’s daughter, 1.67 for his son). Is this epigenetics at work?

http://archpsyc.jamanetwork.com/article.aspx?articleid=1666655; http://archpsyc.jamanetwork.com/article.aspx?articleid=1666654



Marta abused ETOH and marijuana in her ‘20s. She has been a cigarette smoker for about 30 years. Ethan was diagnosed with Autism at age 2.



Vivian and Marta ask you about the likelihood that Conner will also develop Autism—esp after your long‐winded discussion on genetics.



Because Ethan has autism, his younger brother Conner has an approximately 25% chance of also being diagnosed (correctly) with autism.



Myth Fact



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

Because Ethan has autism, his younger brother Conner has an approximately 25% chance of also being diagnosed (correctly) with autism.



Myth

 

S A T U R D A Y

~2 – 8% of siblings of an autistic child will also be diagnosed with autism. One prospective study found 18.7% of siblings eventually were diagnosed with autism spectrum disorders.  Used broader, newer definitions.  High risk children (to get #’s, but ?skew?).

Pediatrics 2006;118:e139-50; Pediatrics 2004;113:e472-86; JChildPsycholPsychiat 1994;35:877-900; AmJHumGenet 1991;49:932-8; JAmAcadChildAdolescPsychiat 1990;29:177-83; Pediatrics 2011;128:e488-95



Marta asks when Ethan will develop artistic or musical or memory skills or other special traits, like Dustin Hoffman in Rain Man.

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

Most autistic people have and/or develop savant skills (e.g., Rain Man).



Myth Fact



Most autistic people have and/or develop savant skills (e.g., Rain Man).



Myth



Difficult to quantify.  “Exceedingly rare” (Researcher at DeMontfort

Univ, UK).  0.06% (1977 institutional survey).  0.14% (2000 institutional survey).  0.5 – 1% of autistics (2001 book).  10% of autistics (2009 review).  28.5% (survey of parents). Philosophical Transactions of the Royal Society B 2009;Biological Sciences 364:1351–7; http://www.psy.dmu.ac.uk/drhiles/Savant%20Syndrome.htm; Hermelin B. Jessica Kingsley Publishers; London, UK: 2001--Bright Splinters of the Mind; Serban G., ed., Cognitive defects in the development of mental illness, Brunner/Mazel; New York, NY, 1978:43–65; PerceptMotSkills 2000;91:120-2; PerceptMotSkills 1977;44:161-2; Philosophical Transactions of the Royal Society B: Biological Sciences 364:1359–1367

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

In any case:  A minority of pts.  All children and pts are unique and special. This is

a pleasant and sometimes helpful way to frame some issues for parents, without giving too much hope/ anticipation of impending cure or savant skills.



Vivian asks: “Will he ever fall in love? Can he get angry?”



Autistic people do not feel emotions.



Myth Fact



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

Autistic people do not feel emotions.



Myth



People with ASDs have difficulty reading & interpreting emotional cues. Difficulty understanding and responding to emotional states or needs of others. Difficulty regulating their own emotions.

 

http://www.uptodate.com/contents/clinical-features-of-autismspectrumdisorders?source=search_result&search=autistic+savant&selectedTitl e=1~51#H1



Autistic children can have emotions. The rest of us have difficulty interpreting their emotions, as they have difficulty interpreting ours.

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

Vivian remembers that the shooter at Sandy Hook elementary in Newtown, CT (12/14/12) may have had an ASD. Will Ethan become violent?



Autistic people have more episodes of violence.

 

Myth Fact



Autistic people do not feel emotions.



Myth

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  

There is no evidence that people with ASD’s commit more violent acts. Aggression or violence in people w/ASDs is not planned or deliberate, may be reactive. 1 review noted that “a small number of serious crimes can be linked to the core features of ASD,” and that comorbid psych conditions were major risk factors.

JAutismDevDis 1991;21:349-53; JInterpersViolence 2009;24:1358-1370; Autism 2000;4:63-83; ResAutismSpectrumDisorders 2012;6:79–86



Marta asks how you can know if little Conner is going to get an ASD.



There is no test for autism.



Myth Fact



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

There is no test for autism.



Myth—sort of



S A T U R D A Y

Modified Checklist for Autism in Toddlers (M‐ CHAT).  16‐30 months, validated.  English/Spanish, ~5th grade reading level.  23 yes‐no questions for parents.  PPV better @ 24 mo vs 18 – do it again!

http://www.uptodate.com/contents/screening-tools-for-autism-spectrumdisorders?source=see_link&anchor=H7#H1; JPedi 2009;154:535-40; JPedi 2009;154:478-80; DevMedChildNeurol 2012;54:514-20; JAutismDevDisord 2001;31:131-44; JAutismDevDisord 2008;38:827-39; Autism 2008;12:513-35; Autism 2008;12:537-56

   

PPV 36% alone, 57‐76% if followed by phone interview. Up to 79% PPV if high risk child. Less reliable in premies <28 wk. There are Asperger screening tools available (ASSQ, CAST, AQ‐Child).

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

12/5/12, PLOS One online: blood test for genetic signature, using a 55‐gene prediction model, has 73% PPV and 72% NPV in males (all male subjects in initial study). Did not perform quite as well w/females. To be continued…

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.p one.0049475



Vivian and Marta ask if there is anything you can do for Ethan, or for Conner if he does turn out to have an ASD.



There is no treatment for autism.



Myth Fact



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There is no treatment for autism.



Myth



There is no cure for autism.

 

Maximize functioning. Move child toward independence. Improve QOL for child and family.



Depends on individual and family.



S A T U R D A Y

Pediatrics 2012;130 Suppl 2:S169-78; PediAnn 2009;38:42-9

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    

Improve social functioning and play skills. Improve communication skills (both functional and spontaneous). Improve adaptive skills. Decrease nonfunctional or negative behaviors. Promote academic functioning and cognition.

Pediatrics 2012;130 Suppl 2:S169-78; PediAnn 2009;38:42-9



Refer to California Regional Center.  21 regional centers providing diagnosis &

treatment for people w/disability beginning before 18th birthday.  All counties of CA are served by a center.  Referral by age 36 months is optimal. 

http://www.dds.ca.gov/RC/Home.cfm



Provide a pt‐centered medical home for your autistic patient and family.   satisfaction.   costs.  Coordination of care.  Transition to adolescence and beyond.

Pediatrics 2011;128:892-900; Pediatrics 2002;110(6 Pt 2):1322-7; Pediatrics 1994;93:602-7

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

Behavioral



Structured teaching

 Applied Behavior Analysis  Treatment and Education of Autistic and related

Communication‐handicapped Children (TEACCH) 



Developmental/relationship‐based

S A T U R D A Y

Best evidence is for intensive behavioral interventions, esp...... Applied Behavior Analysis – this method requires data collection re child and response to therapy.  Reward‐based skill teaching.  Step‐by‐step skill learning.  Goal is acquisition of skills, not return to

normalcy. www.nationalautismcenter.org/pdf/NAC%20Standards%20Report.pdf; http://www.uptodate.com/contents/autism-spectrum-disorders-in-children-and-adolescents-behavioraland-educational-interventions?source=search_result&search=autistic+savant&selectedTitle=4~51#H1



Structured teaching



Developmental/relationship‐based

 Improvements in motor and communication skills.  Evidence inconclusive, some communication

benefits seen in some studies. 

CBT may help high‐functioning ASD pts w/anxiety.

PLoS One 2008;3:e3755; JAutismDevDisord 1998;28:25-32; JIntellectDisabilRes 2002;46(Pt 4):318-27; www.nationalautismcenter.org/pdf/NAC%20Standards%20Report.pdf; http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-andreports/?productid=651&pageaction=displayproduct

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

Disruptive behaviors  Risperidone and aripiprazole are FDA‐approved.

Other neuroleptics not. 

Repetitive behaviors, rigidity  SSRIs used, not approved.  Clomipramine, risperidone, valproate—not

approved.  Poor evidence.



Anxiety  Equivocal evidence for buspirone (open label).  SSRIs not specifically approved in autism, some

evidence in anxiety in children.

CochraneDatabaseSystRev 2009 Jul 8;(3):CD005170; ClinPsychiatry 1998;59:56-9



Depression  SSRIs  No specific evidence in ASDs.  Watch for behavioral activation (impulsivity,

silliness, agitation, and disinhibition).  Watch for other SEs –  risk of suicidal ideation.

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

52‐74% of families of ASD children use CAM (an old term we should dispense with!).  Melatonin: improves sleep (grade A).  Music therapy: may  autistic behavior,  play skills

(A).

 Vitamin C may  stereotypical behavior (B).

JAutis DevDisord 2006;36:901–9; JAutismDevDisord 2007;37:628– 36; AnnClinPsych 2009;21:213–236; CochraneDatabaseSystRev 2006;(2):CD004381



 

Cholinesterase inhibitors (donepezil, rivastigmine, galantamine): improve speech, irritability (grade A, short studies). Naltrexone:  self‐injury behavior, agitation (A). Central ‐2 agonists (clonidine, guanfacine) may  irritability, hyperactivity, insomnia (B).

AnnClinPsych 2009;21:213–236

 

Elimination diets – grade C in prior study. Recent study, gluten‐free/casein‐free diet:  Parents reported improvements in: ▪ Autistic behaviors ▪ GI sx ▪ Food sensitivities ▪ Social behaviors

AnnClinPsych 2009;21:213–236; Nutritional Neuroscience 2012;15:85-91

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

N‐acetylcysteine:  2012 study of 33 autistic children  DB PC RCT  ing doses of NAC (90018002700 mg)   irritability – p<0.001  Few SEs

Biol Psychiatry 2012;71:956-961

 

“Autism” is a spectrum of disease. Mutifactorial etiology (but not mom’s fault)  Genetic, but not simple inheritance

   

Few savants Not habitually violent M‐CHAT for screening Many treatments, but no cure

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Session #9: Saturday, May 4, 2013 | 4:30-5:00 pm Weight Issues for Kids (Janae and Sean Jones)

Lauren Simon, MD, MPH

Activity Description This session is the second of three in a 3x30 block – quick updates on topics of importance to family physicians. Childhood obesity is on the rise and the team of family physician-parents-kids is key to solving the problem. Learning Objectives At the end of the educational activity participants should able to: - Define pediatric overweight and pediatric obesity - Identify co-morbid conditions related to pediatric obesity - List components of weight management, and work with the Jones family to select and implement successful strategies Dr. Simon graduated from Hahnemann University School of Medicine in Philadelphia, Pennsylvania in 1990. She completed a primary care sports medicine fellowship at Kaiser Permanente in Fontana in 1994. Dr. Simon received a master of public health degree at Loma Linda University School of Public Health in 1994. She is board certified with the American Board of Family Medicine, with an added certificate in sports medicine. Dr. Simon was employed with Kaiser Permanente during her sports medicine fellowship and in our extended care department until she joined our group in July of 1994. She is an assistant professor at Loma Linda University School of Medicine. She serves as team physician for University of California, Riverside; University of Redlands, and Redlands High School.

S A T U R D A Y

Dr. Simon provides a broad spectrum of services within her expertise. In addition to providing family care she has special emphasis in sports medicine, obstetrics, and adolescent medicine. You may even find her on the sidelines at your local sporting events. Her vivacious personality and energetic nature attracts patients of all ages. She is committed to providing comprehensive health care for all members of your family. Dr. Simon is a member of the first class of the CAFP CME Leaders Institute and the Cahir of CAFP’s Medical Student and Resident Affairs Committee. Faculty Disclosure: Dr. Simon declares that in the past 12 months neither she, nor any member of her immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

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Weight Issues for Kids Janae and Sean Jones

Lauren M. Simon, MD, MPH, FAAFP, FACSM Associate Professor of Family Medicine Assistant Director, Family Medicine Residency Program Loma Linda University

MEDICAL CENTER

Objectives 



The learner will be able to define pediatric overweight and pediatric obesity The learner will identify co-morbid conditions for pediatric obesity The learner will list components of a pediatric weight management plan The learner will apply weight management strategies to the Carmichael family members Janae and Sean Jones

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Carmichael Family Members 

Sarah Carmichael Jones Age 32 Healthy  Married to Anthony  



Anthony Jones Healthy Former college athlete  Teacher/coach  

S A T U R D A Y

Carmicheal Family (cont)  

Sarah and Anthony have 2 children Daugher Jenae  



Age 10 “Pudgy”

Son Sean Age 8  Slender 



Sarah worries about their weight

Definition of Childhood Obesity 

Body Mass Index for age/gender at or above the 95th percentile

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Child Weight Classifications

Childhood Obesity Trends 



Pediatric overweight and obesity affects up to 30 percent of children Since the 1970s childhood obesity rates tripled for age 2-5 and quadrupled for ages 6-11, 12-19 Morbidity and mortality ramifications are persistent Odds Ratio for childhood obesity if one parent obese=3 If 2 parents obese :OR=>10

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S A T U R D A Y

Body Mass Index    

Screening tool to assess body fatness Track weight relative to height Age specific BMI values BMI persists into adulthood

Percentage of high school students who were obese – selected U.S. states, Youth Risk Behavior Survey, 2011

CDC.gov/healthyyouth/obesity

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S A T U R D A Y

Body Mass Index  Metric Weight (in Kilograms) Height (in Meters)2 Weight ( kg) ÷ Height (cm) ÷ Height (cm)



English Weight (lbs) ÷ Height (in) ÷ Height (in) x703

Visual Diagnosis vs BMI 

Visual diagnosis may underestimate those children at risk for overweight/obesity

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BMI for Age Percentile Chart 

Age horizontal axis



BMI vertical axis



Intersection point is BMI for age percentile

BMI Percentile: Janae and Sean

Pediatric Obesity Co-morbidities     

HTN Pulmonary emboli Polycystic ovarian syndrome Insulin resistance Diabetes DKA Hyperglycemic- hyperosmolar coma  Type 2 Diabetes  

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Pediatric Obesity Co-morbidities       

Hyperlipidemia Restrictive lung disease Cholelithiasis SCFE OA Obstructive sleep apnea NAFLD inflammation /fibrosis / cirrhosis (NASH)

S A T U R D A Y

Pediatric Obesity Co-morbidities   



Pseudotumor cerebri Cardiomyopathy of obesity Future risk of some cancers(eg. endometrial colon and postmenopausal breast cancer) Psychosocial Morbidity Low self esteem Depression  Anxiety  Victim of bullying  

Obesity Link to Diabetes 



Severe obesity ( BMI >97th %tile)Best predictor progression from Pre DM to DM in children and adolescents Other predictors  

Persistent weight gain Increased insulin resistance

Weiss R. et al. Diabetes care 2005, 28:902-909

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Social –Ecological Model and Obesity 

Framework illustrate how elements of society combine to shape an individuals : Food choices Physical Activity choices  Calorie Balance  Chronic Disease Risk  

Dietary Guidelines for Americans, 2010 :Chapter 6 Helping Americans Make Healthy Choices Page 56, Figure 61

A Social Ecological Framework for Nutrition and Physical Activity Decisions

DIETARY GUIDELINES FOR AMERICANS, 2010 – Page 56, Figure 61

Janae and Sean’s Family history 

Carmichael family history MGF Robert: obese, Type 2 DM ,HTN MGM Camille: breast cancer  Maternal Aunt Ruth : died of MI  Father is AA  

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The Built Environment 

Physical form of communities 

Urban design



Land use pattern



Transportation system



Physical appearance and arrangement Commercial, residential

S A T U R D A Y

Janae and Sean’s “Built” Environment       

Jones family lives on cul de sac No sidewalks to any parks Family has one car Parents work late Safety? Access to corner grocery store only Limits food choices to dense ,high calorie options

Assessment for Overweight/Obesity 

History Diet Physical activity  Family history  



CAD, DM, HTN, obesity

Targeted ROS 

Sleep, energy level, mood, respiratory,bowel/bladder

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Dietary Assessment for Overweight/Obese Children   

  

Structured meals vs grazing Breakfast ( CHOs, skipping meal) Beverage choices/volume ( water, juice milk, soda, sports drinks) Fruit and vegetable consumption Eating out ( high salt/ high fat /large portions) Portion sizes for meals and snacks

Medical Assessment      

BMI percentile(no shoes for stadiometer ht) General appearance ( comorbid syndrome?) Neck :thyroid Skin :acanthosis nigricans (glucose intolerance) Abdomen :liver enlargement ( steatohepatitis) MSK :joint exam

Behavioral Assessment     

Identify modifiable risk factors Physical Activity Sedentary Behavior Screen time Food access behavior

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Laboratory Assessment for Childhood Obesity /Overweight 

Overweight children> 9 do fasting lipids



Obese children



If risks factors present also do FBS,ALT,AST Q 2years regardless of risk factors Fasting blood glucose Fasting lipids  Alanine aminotransferase  Aspartate Aminotransferase  

S A T U R D A Y

Question Parents in Risk Assessment 

Are you concerned about your child’s weight? 



  

Cultural norms?

I’m concerned that your child’s weight is getting ahead of his height. Avoid negativity Show the BMI percentile graphs Assess Readiness for Change

Eating Behavior Changes   

  

Reduce frequency of eating outside the home Reduce sugar sweetened beverage intake Reduce fruit juice consumption to less than 1 cup per day Monitor portion sizes Reduce high sugar/high fat foods E.g. Try adding one fresh fruit serving per day

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Not just calories… Macronutrients Proportions by Age

Activity Behavior 

Goal 60 or more minutes per day of Physical Activity for children and adolescents 

2008 Physical Activity Guidelines for Americans Aerobic, muscle strengthening and bone strengthening activities.  Vigorous intensity aerobic activity 3 or more days per wk 



Active transportation 

E.g. Walk to school one or more days/wk

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Promote Physical Activity     



Free unstructured play Outdoor time Organized Parental role models Decrease screen time (TVs videos computers) less than 2 hours per day Screen time decreases energy expenditure and increases energy intake

S A T U R D A Y

Rewards      

Praise Privileges Activities Time with parents Money NON FOOD rewards

Eating Behavior 

 

  

Encourage family meals with Incr Fruits/vegetables Avoid eating in front of TV Portion control Eat till “satisfied” not to feel full Chew food 10-20 times Consider child serve his/her portions

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Resources       

Let’s Move ( www.letsmove.gov) My Plate.gov 2008 Physical Activity Guidelines for Americans Dietary Guidelines for Americans,2010 AAFP AIM-HI (Americans in Motion) AAP (Healthy Children.org) Exercise is Medicine

My Plate.gov

Prevention An ounce of prevention is worth “pounds of cure”

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Let’s Move 

First Lady Micelle Obama’s initiative to solve childhood obesity problem 

Launched 2/9/10

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Behavior Changes 

Keep it simple and keep it FUN

Useful Websites 

Child and Adolescent BMI calculator



Growth Charts



http://apps.nccd.cdc.gov/dnapmi/ http://www.cdc.gov/growthcharts



Let’s Move



My plate.gov



www.letsmove.gov

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Session #10: Saturday, May 4, 2013 | 5:00-5:30 pm

Best Practices for Secondary Stroke Prevention (Kwan Lee)

Mark Dressner, MD

Activity Description This session is the final hit in a 3x30 block – quick updates on topics of importance to family physicians. Stroke can be prevented and the risk of stroke post-TIA or previous stoke can be decreased. Dr. Dressner will discuss some tools to use and therapies to implement as you address stroke risk and atrial fibrillation. Learning Objectives At the end of this educational session participants should be able to: - List at least 5 methods with numeric goals, to decrease risk of stroke after a TIA or previous stroke. - Explain the rationale for using, or not using, 2 antiplatelet agents together. - Name 5 factors that increase the risk of stroke in atrial fibrillation and 4 treatment options. Dr. Mark Dressner is a staff physician in the adult section of The Children’s Clinic, a Federally Qualified Health Center (FQHC), in Long Beach, California. Dr. Dressner graduated from the Sackler School of Medicine at Tel Aviv University, and completed his residency at the University of Cincinnati. He also holds a Master’s Degree in Education from the University of Southern California. He formerly worked for 15 years in residency education, winning several awards for teaching. He has been on 14 medical brigades to Honduras and 2 to Brazil. Dr. Dressner will be sworn-in as President of the California Academy of Family Physicians (CAFP) on Saturday, Mary 4, and served for three years as editor of California Family Physician magazine.

S A T U R D A Y

Faculty Disclosure: Dr. Dressner declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. This session is presented as part of The Evolution of Anticoagulation Management-Atrial Fibrillation (TEAM-A) initiative. TEAM-A is supported by an unrestricted educational grant for the Bristol-Myers-Squibb/Pfizer Partnership.

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Stroke – Evidence for Secondary Prevention Focus on Kwan Lee Late husband of Sally Carmichael Lee Robert Carmichael’s sister

2013| California Academy of Family Physicians

Mark Dressner, MD Dr. Mark Dressner is a staff physician in the adult section of The Children’s Clinic, a Federally Qualified Health Center (FQHC), in Long Beach, CA. He has taught in residency programs for 15 years, holding a Masters in Education from USC. He is currently President of the California Academy of Family Physicians.

Disclosure and Industry Support 



It is the policy of CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all of their continuing education activities.



Dr. Dressner declares that in the past 12 months neither he nor any member of his family have had a financial arrangement or affiliation with any corporate organization offering financial support of grant moneys for this continuing education program.

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Objectives: 1) List at least 5 methods to decrease risk of stroke after a TIA or previous stroke 2) Explain the rational for using, or not using, 2 antiplatelet agents together 3) Name 5 factors that increase the risk of stroke in atrial fibrillation and 4 treatment options.

S A T U R D A Y

Hypertension • Reduction even if no HTN • Benefit 10/5 • Lifestyle modification • Best diuretics or diuretics and ACE

Lipids • LDL > 100 without know CAD • At least 50 % reduction in LDL or < 70 • Low HDL consider niacin or gemfibrozil • Role of statins

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Smoking • Nurses’ Health Study RR 2.58 of stroke • Risk disappears within 2-4 years • Looking at multiple studies risk eliminated by 5 years

Alcohol • Protected light to moderate • 2 drinks/day men, 1 drink/day women • Non drinkers should not start

Antiplatelet Agents • ASA • Clopidogrel • ASA/dipyridamole

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Unusual causes • Antiphospholipid syndrome • Protein C • Protein S • Antithrombin III • Factor V Leiden • Prothrombin G20210A mutation

S A T U R D A Y

New Guideline • tPA Now 4.5 hours from onset of stroke increased from 3 hours. • New guidelines from Stroke March, 2013.

In Summary • Antiplatelet • Statin • Diuretic • ACE or ARB • Smoking • Education • Call 911, get in right away

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Main Source • Stroke. 2011;42:227-276 Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professional from the American Heart Association/American Stroke Association

Antiplatelet Therapy Total Bleeding 4.8 % ASA 2.9 % Clopidogrel alone 10.1 % ASA and Clopidogrel Major Bleeding 1% ASA 0.85 % Clopidogrel 1.7% ASA and Clopidogrel

Antiplatelets in CAD • Lower risk Cardio events OR = 0.87 • Higher risk for major bleeding OR = 1.34 • Prevent 13 coronary events per 1,000 but 6 major bleeds • But if acute non-ST coronary syndrome prevent 23 events per 1,000 with 10 bleeds

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Antiplatelets in CAD • High cardiovascular risk but not acute coronary event 5 events prevented per 1,000 with 3 major bleeds

S A T U R D A Y

Antiplatelets in Atrial Fib. • Major vascular events 6.8% ASA and clopidogrel and 7.6% ASA alone • Stroke 2.4% ASA and clopidogrel and 3.3% ASA alone • Major bleeding 2.0 % ASA and clopidogrel and 1.3 % ASA alone

CHADS2: A Validated Classification Scheme for Stroke Risk • Derived from a Medicare cohort of 1,733 patients with AF (who were not anti-coagulated) • Assigned points for stroke risk:

▫ ▫ ▫ ▫ ▫

CHF HTN Age>75 DM Stroke/TIA

1 1 1 1 2

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The CHADS2 Index Stroke Risk Threshold Favoring Anticoagulation

Approximate Risk threshold for Anticoagulation

Score (points)

Risk of Stroke (%/year)

1.9

2.8

2 3 4 5 6

4.0 5.9 8.5 12.5 18.2

3%/year

Bleeding Risk Major Bleeding %/Year

Intracerebral Hemorrhage %/Year

Age

Aspirin

1.2

0.2

Aspirin + clopidogrel

1.8

0.4

0.1-0.6

6980

Antithrombotic

Warfarin

1.2

Dabigatran (150)

3.1

0.3

Rivaroxaban

2.9

0.4

Apixaban

2.0

0.3

Remember: Untreated patients with nonvalvular AF have a 5-fold increased risk of stroke Guo Y, et al. Pol Arch Med Wewn. 2012;122(5):235-242., Wolf PA, et al. Stroke. 1991;22(8):983-988. Fuster V, et al. Circulation. 2011;123(10):e269-367.

Resources â&#x20AC;˘ www.TEAManticoag.com

â&#x20AC;˘ Circulation March 2011, supplement

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Schedule for Sunday May 5 2013_____________________________________

Page

9:00-10:00 am

Building an Adult Immunization Practice: 192 The Primary Care Physician’s Role in Disease Prevention (Marta Perez) Patrick Joseph, MD Michael D. Hogue, PharmD

10:00-11:00 am

Improving Diabetes Outcomes: 220 Placing the Patient at the Center (Robert Carmichael) Bo Greaves, MD Chris Sadler, PA-C

11:30-12:15 pm

Cancer Screening in Family Medicine 235 (Sarah Jones) William Woo, MD

12:15-1:15 pm

Restless Legs Syndrome— Causes, Consequences and Clinical Management 251 (Sally Carmichael) Paul Doghramji, MD Karl Doghramji, MD

S U 1:15-1:30 pm Closing Remarks David Bazzo, MD N 1:30-3:30 pm Workshop: ICD-10 and what 270 D you need to know to change the way you code! Mary Jean Sage A Y

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Session #11: Sunday, May 5, 2013 | 9:00-10:00 am

Building an Adult Immunization Practice: The Primary Care Physician’s Role in Disease Prevention (Marta Perez) Patrick Joseph, MD Michael D. Hogue, PharmD

Activity Description This session, using the case of Marta Perez, will provide the latest information on adult immunizations, including benefits and barriers seen in the family medicine practice. This activity is support by an educational grant from National Foundation for Infectious Diseases (NFID), as part of a project supported by Merck. Learning Objectives At the end of this educational activity participants should be able to: - Recognize the clinical consequences of vaccine-preventable diseases in adults - Identify adult patients who will benefit from vaccination - Reduce and remove system- and patient-related barriers to vaccination Dr. Patrick Joseph is an Associate Clinical Professor of Medicine at the University of California, San Francisco and the current Vice President of the National Foundation for Infectious Diseases. He did his specialty training in Infectious Diseases at the University of California in San Francisco and has been actively involved with epidemiology, teaching, and private practice in California for the past 30 years. Since 1990, Dr. Joseph has been the medical director of the Adult Immunization Clinic in the San Francisco area and has been closely involved with diagnosis, treatment, and prevention of vaccine-preventable diseases. When the Pertussis outbreak began in California, Dr. Joseph was one of several who encouraged the California Department of Health to extend the indications for adult Pertussis vaccine to all adults and lift the age restriction for those over 64. That initiative was quickly successful in California, and subsequently has been adopted by the United States Public Health Service and the Centers for Disease Control and Prevention. Dr. Joseph has received numerous awards and honors, including being named as one of America’s Top Physicians and the Best Physicians in America several times. Michael D. Hogue, PharmD is chair, Department of Pharmacy Practice, and associate professor at Samford University’s McWhorter School of Pharmacy, Birmingham, AL, where he serves on the school’s administrative leadership team. Dr. Hogue is the 2011‐13 President of the American Pharmacists Association’s (APhA) Academy of Pharmacy Practice and Management, and is a member of the Board of Trustees of APhA. He has held numerous leadership positions in APhA and the Alabama Pharmacy Association. He was elected to the board of directors of the National Foundation for Infectious Diseases in 2012. 192

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Dr. Hogue served on the initial profession‐wide consensus conference charged with defining Medication Therapy Management following the adoption of the term in the Medicare Modernization Act of 2003, and served for three years on the Pharmacy Services Technical Advisory Committee (PSTAC). He has published three books, two of which are related to compensation for pharmacists’ services, and written numerous book chapters and refereed manuscripts. Dr. Hogue was on the APhA development team for the creation of pharmacy‐based immunization delivery training, and was one of the original faculty members of APhA’s immunization certificate training program when the program was launched in 1996. He is recognized as an expert in vaccines and methods for improving access to immunization services, as well as compensation for pharmacist‐provided non‐dispensing services. As a part of his academic leadership position at Samford, Dr. Hogue coordinates the school’s global pharmacy education efforts. He is married to a pharmacist, Dr. Heather Hogue, and has two daughters Faculty Disclosure: Dr. Joseph declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. Dr. Hogue declares that in the past 12 months he has received honoraria from Pfizer and served as a consultant/ advisory board member for Pfizer. The educational planning staff from the National Foundation for Infectious Disease, Marla Dalton, Joan Colbourne, Maya Drenovac, and Marco Cicero, declare that in the past 12 months neither they, nor any members of their immediate families, have had a relevant financial interest in corporate entities supporting this meeting. In compliance with its policy for Conflict of Interest identification, management and resolution, the CAFP’s Committee on Continuing Professional Development reviewed and approved this session. This activity is support by an educational grant from National Foundation for Infectious Diseases (NFID), as part of a project supported by Merck.

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S A T U R D A Y

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Sunday, May 5, 2013 San Francisco, CA

ACTIVITY INFORMATION Target Audience

This educational activity is designed for primary care providers, including family physicians, internists, nurse practitioners, physician assistants, nurses, and other allied healthcare professionals who are at the forefront of managing adults at risk for vaccine-preventable diseases.

Learning Objectives

At the conclusion of this activity, participants will be able to:  Recognize the clinical consequences of vaccine-preventable diseases in adults  Identify adult patients who will benefit from vaccination  Reduce and remove system- and patient-related barriers to vaccination

ACCREDITATION Physicians This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the National Foundation for Infectious Diseases (NFID) and Vemco MedEd, LLC. NFID is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NFID designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Instructions for Credit

AAFP Credits are offered through CAFP To receive a Certificate of Credit from NFID, participants must attend the session and complete the online evaluation following the activity. Note that you may only claim credit though either AAFP or NFID. Visit http://questionpro.com/t/ABzNyZPRTb to complete the evaluation. For questions regarding this activity, please contact NFID at cme@nfid.org.

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FACULTY Patrick Joseph, MD Associate Clinical Professor of Medicine University of California, San Francisco San Francisco, CA Michael D. Hogue, PharmD Chair, Department of Pharmacy Practice Associate Professor, McWhorter School of Pharmacy Samford University Birmingham, AL

DISCLOSURES Faculty Patrick Joseph, MD has no relevant financial relationships to disclose. Michael D. Hogue, PharmD serves on the Advisory Board and serves as a speaker or a member of a speakers bureau for Pfizer Inc.

Planning Committee Marla Dalton (NFID) owns stock, stock options, or bonds from Merck & Co., Inc. Len Novick (NFID) owns stock, stock options, or bonds from Cubist, Novavax, Pfizer Inc., and ViroPharma. Susan J. Rehm, MD (NFID) serves as a consultant/advisor for Becton Dickenson, Merck & Co., Inc., and Pfizer Inc., and serves as a speaker or a member of a speaker’s bureau for Genentech. All other NFID and Vemco MedEd staff have no relevant financial relationships to disclose.

S U N D A Y

ACIP Adult Immunization Schedule www.cdc.gov/vaccines/schedules/downloads/adult/adult‐schedule.pdf

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Case Study Marta Perez is a 52 year old Hispanic female. She was born in Central America in 1961 and immigrated to the US in 1986. She has no prior health records and no documents regarding her entry into the US.

Case Study When she was 20 years old, her parents were killed in a motor vehicle accident. For the next 3 years she drank alcohol and used marijuana daily. When asked, she would not comment on using intravenous drugs. She has smoked Â˝ pack per day for >25 years, but denies alcohol or any drug use for the past 10 years. She met her life partner, Vivian in 1998, and they have been together for the past 15 years. They have adopted two biological brothers, aged 4 months and 18 months. Marta Perez has not received any immunizations in the past 2 years.

Promoting Adult Immunization Against Vaccine-Preventable Diseases Pneumococcal Disease Michael D. Hogue, PharmD Chair, Department of Pharmacy Practice Associate Professor, McWhorter School of Pharmacy Samford University Birmingham, AL

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Polling Question–Pneumococcal Disease Although a smoker for >25 years, Ms. Perez has no knowledge of having lung disease. Which of the following would you recommend for Ms. Perez? A. Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax® 23) B. Pneumococcal 13-valent conjugate (Prenvar®, PCV13) C. 1 dose of PCV13 followed by PPSV23 eight weeks later D. No pneumococcal vaccine is warranted at this time

Streptococcus pneumoniae  Gram-positive, diplococci  Normal inhabitant of the human upper respiratory tract  Most common cause of respiratory tract infections (community-acquired pneumonia [CAP], sinusitis, and otitis media)  Leading cause of invasive bacterial diseases in children and adults

Lynch J, Zhanel GG. Curr Opin Pulmon Med. 2010;16:217-225.

S U N D A Y

Clinical Problem with Pneumococcal Disease

Pneumococcal disease remains a substantial cause of morbidity and mortality in the US even in the era of routine pediatric and adult vaccination

Huang SS, et al. Vaccine. 2011:29:3398-3412.

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Pneumococcal Disease: Major Clinical Syndromes Meningitis

Annual cases: 3,000 Case-fatality rate: 30%

Bacteremia

Annual cases: 50,000 Case-fatality rate: 20%

Pneumonia

Annual cases: 500,000 Case-fatality rate: 5–7%

Less severe diseases (sinusitis, otitis media): Millions of cases annually 1.CDC. The Pink Book. 10th ed. Washington DC: Public Health Foundation, 2007. 2.CDC. MMWR Morb Mortal Wkly Rep. 2005;54(RR-5):1–11.

Estimated Number of Cases of Invasive Pneumococcal Disease (IPD)*, 2011 Age (years)

Rate/100,000**

16.9

2-4

8.3

5-17

2.0

18-34

3.2

35-49

9.1

50-64

18.7

>65

National Estimate of Invasive Disease Cases: 36,850 (11.8/100,000) *IPD: Streptococcus pneumoniae isolates from sterile sites (i.e. bacteremia and meningitis) **Data Source: CDC, Active Bacterial Core Surveillance (ABCs), 2011 data: Emerging Infections Program Network. Available: www.cdc.gov/abcs/reports-findings/survreports/spneu11.html. Data for the table is applicable to the core surveillance areas and may or may not apply nationally.

Streptococcus pneumoniae: Vaccine History

Year

Name

1977

Pneumovax®14

1983

Pneumovax®23

2000

Prevnar®7 (PCV7)

2010

Prevnar®13* (PCV13)

FDA Approved

Vaccine Type

Retail

≥2 years old

Polysaccharide (PPSV23)

$ 45

6 weeks – 6 years

Polysaccharideprotein conjugate

$ 115

*Prevnar-13 FDA licensed for use in adults 50 years and older in December 2011; FDA approved indication differs from ACIP recommendations for use at this time

Centers for Disease Control. Pink Book. Available: www.cdc.gov/vaccines/pubs/pinkbook/index.html

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Pneumococcal Vaccination Rates in US Adults, 2011 100 90 80 70

White (not Hispanic or Latino)

Average for group

Black (not Hispanic or Latino) Hispanic or Latino

66.5

Asian

62.3

60 47.6

Percent Vaccinated 40 30 20

20.1

22.8

18.3 12.0

10 0

43.1

40.3

20.1

19-64 years (with high- risk conditions)

> 65 years

DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2011. Estimates are based on household interviews of a sample of the civilian non-institutionalized population. Data available: www.cdc.gov/mmwr/preview/mmwrhtml/mm6204a2.htm?s_cid=mm6204a2_w#tab1

Rates of Pneumococcal Conjugate Vaccine (PCV7-type) Invasive Pneumococcal Disease among Adults, US 1998/99-2006 PCV7

>80 yrs

Cases per 100,000

60 50 40

65-79 yrs

30 20

50-64 yrs

10 0

18-49 yrs 1998

1999

2000

2001

2002

2003

2004

2005

2006

S U N D A Y

Centers for Disease Control. Available: www.cdc.gov/vaccines/pubs/pinkbook/downloads/pneumo.pdf.

Changing S. pneumoniae Serotypes (2007–09, n=800)

PCV13

Pneumovax

≥50 years (n=430) 17-49 years (n=240) 3-16 years (n=70) ≤2 years (n=60)

PCV7

4 6B 9V 14 18C 19F 23F 5 7F 3 6A 19A 9N 10A 11A 12F 15B 17F 20 22F 33F 6C 6D 7C 8 9A 9L 10F 11F 13 15A 15B 15C 16F 21 22A 23A 23B 25F 28A 29 31 34 35A 35B 35F 37 38 NT

Adam HJ, Zhanel GG, et al. Microb Drug Resist. 2012;18(2):176-82.

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Effectiveness of PPSV23 Vaccine  Vaccine strains account for 88% of bacteremic pneumococcal disease  75% efficacy against invasive disease  30% efficacy against pneumonia

File TM, et al. Infect Dis Clin Pract. 2012;20:3-9.

PPSV23 Vaccine: Contraindications and Precautions  Severe allergic reaction to a vaccine component or following a prior dose  Moderate or severe acute illness

Pneumovax®23 Prescribing Information. Merck & Co. Whitehouse Station, New Jersey. October 2011.

Adult PPSV23 Vaccine: ACIP Recommendations  ALL Adults 65 years of age and older  Adults 19-64 (immunocompetent): – chronic illness (heart, lung, liver, diabetes, alcoholism, CSF leaks, cochlear implants) – Asthma* – cigarette smoking*

ACIP. MMWR. 2010;59(34):1102-1106.

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Adult PPSV23 Vaccine: ACIP Recommendations  Adults 19-64 (immunocompromised): – HIV, chronic renal failure/nephrotic syndrome, malignancy, immunosuppressive drugs (steroids, radiation), solid organ transplant, congenital, or acquired immunodeficiency – functional or anatomic asplenia (e.g. splenic dysfunction, splenectomy)

ACIP. MMWR. 2010;59(34):1102-1106.

Effectiveness of PCV13 Vaccine  Strains cover approximately 58% of sterile site isolates  Approval based upon immunogenicity data  Clinical efficacy unknown – CAPITA Trial underway of nearly 85,000 patients in the Netherlands • Examining efficacy in the prevention of pneumonia and IPD in patients >65 years of age • Estimated Primary Completion Date August 2013

S U N D A Y

CAPITA Trial Information. Available: http://clinicaltrials.gov/ct2/show/NCT00744263.

PCV13 Vaccine: Contraindications and Precautions  Severe allergic reaction (i.e. anaphylaxis) to a previous dose of PCV13, or to diphtheria-toxoid containing vaccines.

Prevnar®13 Prescribing Information. Pfizer Inc. Available: www.prevnar13.com.

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PCV13 Vaccine in Adults  2010 FDA approved and ACIP recommends for children 6 weeks–71 months  December 30, 2011 FDA approves for adults:

– Prevention of pneumonia and IPD ≥50 years – Based upon immunogenicity data (non-inferiority to PPSV) – Safety in ~6000 adults similar to PPSV23

 June 20, 2012 ACIP recommends for adults ≥19 years with immunocompromising conditions  February 2012, ACIP recommends 1 dose for children 6 through 18 years who have not previously been immunized and are at a high risk of IPD due to: – – – –

Immunocompromising conditions Asplenia Cochlear implants CSF leaks

ACIP. MMWR. 2012;61:394-395.

PCV13 Vaccine in Adults (administration)  Pneumococcal (PPSV23) vaccine naïve subjects: – Adults ≥19 years of age with immunocompromising conditions (followed by PPSV23 at least 8 weeks later)

 Previously PPSV23 vaccinated subjects: – Adults ≥19 years of age with immunocompromising conditions one or more years AFTER PPSV23

ACIP. MMWR. 2012;61:394-395; ACIP June 20, 2012.

Summary: ACIP Recommendations  Immunize adults with age- or condition-specific indications with one dose of PPSV-23.1  Immunize certain high risk adults with a second dose of PPSV-23, 5 years of age or older after the first dose.1  Immunize certain immunocompromised patients with 1 dose of PCV13.2 This is in addition to recommended doses of PPSV-23.  All patients should also receive a dose of PPSV-23 at age 65 years or older. 1. MMWR. 61(21);394-95. 2. Centers for Disease Control. Available: www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-jun12.pdf

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Summary: ACIP Recommendations Immunocompromised Patients  All immunocompromised patients should receive 2 doses of PPSV-23, separated by 5 years.  Vaccine naïve patients should receive 1 dose of PCV13, followed at least 8 weeks later by PPSV-23.  Patients having previously received PPSV-23 should receive 1 dose of PCV13 one or more years after the last dose of PPSV-23.

Centers for Disease Control. Available: www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-jun12.pdf

Promoting Adult Immunization Against Vaccine-Preventable Diseases Pertussis Patrick Joseph, MD

Associate Clinical Professor of Medicine University of California, San Francisco San Francisco, CA

S U N D A Y

Polling Question-Pertussis Neither Ms. Perez nor her partner has ever been pregnant. Both children are on schedule for childhood immunizations and have received at least two doses of DTaP. Which of the following would you recommend for Ms. Perez? A. Blood test for pertussis antibody B. Tdap C. Dtap D. None of the above

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Bordetella pertussis

Centers for Disease Control and Prevention. Vaccines and Immunizations. Available: www.cdc.gov/vaccines.

Pertussis Incidence by Age Group, 1990-2010

Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System, 2010. Available: www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb11/02-2-pertus-surveil.pdf.

Pertussis US Cases 2009 2010 2011 2012

16,858 27,555 18,719 >30,000

California California Cases Deaths 258 9,154 2,937 <300

3 infants* 10 infants* 0 0

*â&#x2030;¤2 months old and before beginning DTaP series

Centers for Disease Control and Prevention. Vaccines and Immunizations. Available : www.cdc.gov/vaccines. California Department of Public Health. Available: www.cdph.ca.gov/healthinfo/discond/pages/pertussis.aspx.

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Pertussis Epidemic Overview  Waning immunity in adults from childhood DPT and DTaP  Loss of herd immunity  Adults get milder, but contagious disease  Transmit to susceptible infants  Immunize adults with new vaccine (Tdap) to prevent infant deaths

Pertussis Vaccines DTaP

Tdap

(many)

Adacel®

Boostrix®

Tetanus Toxoid (Lf)

5-10

Diphtheria Toxoid (Lf)

15-25

2½

10-25

2½

2 months

11-64 years

≥10 years

5 doses

1 dose

Pertussis Toxin (mcg) Age Regimen

S U N D A Y

ACIP Recommendations for Tdap 1. One shot during EACH pregnancy Otherwise…

2. Everyone >11 years old… once only No waiting period after last Td. Give Tdap ASAP

3. (Currently) 10 years after Tdap, return to routine Td every 10 years

CDC. MMWR. 2012;61(25):468-470. & ACIP Advisory Oct 24, 2012.

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Promoting Adult Immunization Against Vaccine-Preventable Diseases Influenza Michael D. Hogue, PharmD Chair, Department of Pharmacy Practice Associate Professor, McWhorter School of Pharmacy Samford University Birmingham, AL

Polling Question-Influenza During flu season, Ms. Perez should receive which of the following? A. Inactivated trivalent influenza injection (IIV-3) B. Inactivated trivalent influenza injection, high dose (IIV-3 â&#x20AC;&#x201C; High dose) C. Inactivated quadrivalent influenza injection (IIV-4) D. Live, attenuated intranasal influenza vaccine, quadrivalent (LAIV)

Primary Discharge Diagnoses for Pneumonia & Influenza Hospitalizations 350

Rate per 100,000 person-years

300 250 200 150 100 50 0

5-49

Thompson WW. JAMA 2004; 292(11): 1333-40.

50-65

65-69

70-74

75-79

80-84

85+

Age in years

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Influenza Influenza: Enveloped RNA virus

 Family: Orthomyxoviridae  3 types, different surface Ag [HA, NA] + internal structure

– A: Multiple hosts - Birds, Mammals [Human] • Many HA, NA Types • ‘Highly Pathogenic Strains’ • ‘Mild Strains’

– B: Human host

• 1 HA and 1 NA

– C: Human host

• Mild illness ‘URI’

Ag, antigen; HA, hemagglutinin; NA, neuraminidase Centers for Disease Control and Prevention. Influenza viruses. Available: www.cdc.gov/flu/avian/gen-info/flu-viruses.htm.

Influenza Neuraminidase

 Influenza A genome encodes 2 major surface glycoproteins – 16 HA subtypes – 9 NA subtypes – All may be found in avian population – Three (H1, H2, H3) in humans

Hemagglutinin

 Hallmark of influenza virus is ability to undergo constant change

S U N D A Y

Clinical Presentation  “Typical” – Fever, cough, myalgia

 “Atypical” (children, older adults, hospitalized patients) – Fever (non-localizing) – Cough (without fever) – Decompensation of chronic illnesses • CHF & COPD

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Clinical Consequences  Laryngotracheobronchitis  Pneumonia – Viral, 2nd bacterial & ARDS

 Hospitalization  Death  Less common: – Myositis – Reye Syndrome,

 Increased work/school absenteeism  Presenteeism Cate TR. Am J Med. 1987;82: 15-19.

Influenza Vaccines Seasonal vaccine changes annually  Egg-based vaccine production: ~9 months  Recombinant hemagglutinin purified protein (Baculovirus Expression Vector Technology) vaccine production: 21 days  Strain choice (Feb) reflects Antigenic drift [Prior season + Southern Hemisphere]

 Since 1977 the predominant strain types [Disease & Vaccines] – A H1N1, A H3N2, B

Centers for Disease Control and Prevention. ACIP Presentation Slides February 2011 Meeting. Available: www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-feb11.pdf Centers for Disease Control and Prevention ACIP Presentation Slides February 2013 Meeting. Available: http://streaming.cdc.gov/vod.php?id=8db68ce42239c6596904220900acd77420130315193019556.

Influenza Vaccines Seasonal vaccine changes annually  2013-14 Trivalent (IIV-3) Vaccine strains: – A/California/7/2009 (H1N1)-like virus – A/Texas/50/2012 (H3N2)-like virus – B/Massachusetts/2/2012-like virus (from the B/Yamagata lineage of viruses)

 2013-14 Quadrivalent (IIV-4)Vaccine strains: – Above Strains – B/Brisbane/60/2008-like virus (from the Victoria-lineage of viruses) US Food and Drug Administration. www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/PostMarketActivities/LotReleases/ucm343828.htm

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Influenza Vaccine Priorities  HEALTHCARE WORKERS – At risk for disease (symptomatic and asymptomatic) – At risk for transmission – If sick, not available to provide healthcare OR worse presenteeism

 PATIENTS @ Highest Risk (severe illness/spread) – – – – – –

Pregnant women Newborns and children Elderly “Medical Comorbidities” Household contacts of high-risk Long-term care, institutionalized, crowded living conditions

Centers for Disease Control and Prevention. Inactivated Influenza Vaccine 2011-12. Available: www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf.

Who SHOULD Receive Influenza Vaccine?

S U N D A Y

MMWR. 2010; 59: RR-8.

Who Should NOT Receive Influenza Vaccine?  Prior severe allergic reaction to influenza vaccine or to any vaccine components  Severe (anaphylactic) reaction to egg protein  GBS within 6 weeks of influenza vaccination

Centers for Disease Control and Prevention. Available: www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm?s_cid=mm6033a3_w

16 May 3-5 • San Francisco

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Influenza Vaccination for Persons Who Report Allergy to Eggs

Centers for Disease Control and Prevention. :Available: www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm?s _cid=mm6033a3_w

Types of Influenza Vaccines Influenza Vaccine Live Attenuated

Inactivated Vaccine

Trivalent 2012-2013 Quadrivalent 2013-14

Trivalent Standard Dose

Quadrivalent*

High Dose

Intramuscular Intradermal

Live Attenuated Vaccine (LAIV)  Cold-adapted nasal  Licensed only for healthy people 2-50 years  “Formula” changing

– 2012-13: trivalent (H1N1, H3N2, B) – 2013-14: quadrivalent (H1N1, H3N2, 2 B’s)

 Recent studies show decreased efficacy in adults compared to IIV-3 (72% vs 29%)

Monto AS, et al. N Engl J Med. 2009; 361(13):1260-7.

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Intradermal Inactivated Vaccine      

Trivalent Approved May 2011 For adults 18-64 years Microinjection system Total Volume: 0.1 mL 27 mcg HA total

– 9 mcg for each viral strain

Available: www.fluzone.com/intradermal-vaccine/index.cfm Available: www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM305080.pdf

Intradermal Delivery Device

S U N D A Y

Available: www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM305080.pdf

High Dose IIV-3    

65+ population* Same production process as IIV Higher Ag dose = 60 mcg total per antigen Seroconversion, seroprotection rates ≥IIV-3 for A, B strain

– Superiority criteria for A, non-inferiority for B strain

 Local reactions more frequent but “mild”  1st available in 2010-11  ‘Real world’ effectiveness data pending *Falsey AR et.al. J Infect Dis. 2009;200:172-180.

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Adverse Effects  Local reactions: Soreness at vaccination site – Mild, rarely interfered with ability to conduct usual activities  In placebo-controlled trials, no association with higher rates for systemic symptoms – Fever, malaise, myalgia, headache  CANNOT get influenza from inactivated vaccine  Rare AEs

CDC. MMWR. 2009;58:1-52.

Adverse Effects: Rare or Not Associated  Immediate hypersensitivity: 1 per 500,000  Guillain-Barré Syndrome:

– In general population annual incidence 10-20/million – Except for possibly associated with 1976 vaccine, no compelling evidence of association with influenza vaccine (including 2009 H1N1)

 Ocularespiratory Syndrome

– In one placebo-controlled trial, 2% – Red eyes, cough, wheezing, chest tightness within 224hours; resolve within 24 hours; If no evidence of hypersensitivity can receive subsequent IIV

 AUTISM: Absolutely NO ASSOCIATION!!! CDC. MMWR. 2009;58:1-52.

Benefits/Obligations of Influenza Vaccine for Healthcare Professionals  As HCPs we all have an obligation to protect our patients – Transmission may occur without illness • May be asymptomatic carriers • Infectious prior to onset of symptoms

– Studies show reduced transmission after vaccination

 Protection from acute illness  Protection of family members  Mandatory immunization of HCPs  HCP influenza vaccination rates will be publically reported to CMS starting January 2013

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Resources  www.cdc.gov  www.immunize.org  www.nfid.org  www.nhs.uk

Summary  Influenza vaccines prevent the disease  Advances in scientific knowledge have led to major increases in the number of diseases which are vaccine-preventable  Responsible healthcare professionals must increase education of public and encourage usage  PRACTICE WHAT WE PREACH – Support Mandatory Influenza vaccination fro HCPs

 “BE VACCINE CHAMPIONS”

S U N D A Y

Promoting Adult Immunization Against Vaccine-Preventable Diseases Herpes Zoster Patrick Joseph, MD

Associate Clinical Professor of Medicine University of California, San Francisco San Francisco, CA

20 May 3-5 • San Francisco

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Polling Question–Herpes Zoster One child has been immunized against chicken pox, and one child has not. Ms. Perez does not recall if she had chicken pox as a child. Which of the following would you recommend for Ms. Perez? a. 2 doses of Varivax® b. 1 dose of Varivax® followed by Zostavax® 8 weeks later c.

1 dose of Zostavax®

d. Blood test for varicella antibody

Herpes Zoster (Shingles)

Patients with post-rash Pain (%)

Duration of Pain after Rash Heals Increases With Age 100 80 60 40

>1 year 6-12 mo

1-6 mo

0 <20 20-29 30-39 40-49 50-59 60-69

>70

Age (years) de Moragas JM, Kierland RR. AMA Arch Derm. 1957;75:193-196.

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Varicella Zoster Vaccines (Live, attenuated virus vaccines)

Chicken Pox

Shingles

Varivax®

Zostavax®

1995

2006

≥1 year

≥50 years

Doses

Two

One

Strength (pfu)

1,350

19,400

Licensed Approved Age

Herpes Zoster Clinical Trial  Compared to the placebo, the vaccine group had: – 51% fewer episodes of zoster – less severe disease – 66% less postherpetic neuralgia

 No significant safety issues were identified

S U N D A Y

Oxman MN, et al. N Engl J Med. 2005;352:2271-84.

Pre-Vaccination Screening Recommendations  Born in the US before 1980-assumed to have had chickenpox*  Screening for antibody not necessary or recommended before herpes zster vaccine  But… if done and IgG negative-give 2 doses of of varicell vaccine (Varivax®) *except HCPs, pregnant, immunocompromised

Harpaz R, et al. MMWR. 2008;57(RR-5):1-30.

22 May 3-5 • San Francisco

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ACIP Recommendations for Herpes Zoster Vaccine  Single dose for adults ≥60 years old – FDA approved for ≥50 years old

 GIVE even if previously had shingles !!!  Can give with Td, Tdap, or pneumococcal polysaccharide vaccine (ACIP) – FDA (March 2011) recommends to separate herpes zoster vaccine and PPSV by 4 weeks

Harpaz R, et al. MMWR. 2008;57(RR-5):1-30. & FDA Advisory, March 2011 + updated Merck package insert.

ACIP Adult Immunization Schedule www.cdc.gov/vaccines/schedules/downloads/adult/adult‐schedule.pdf

NFID Resources for Patient Education Materials 1. Disease and Vaccination Information: adultvaccination.org/vpd 3. Adult Vaccination Fact Sheet adultvaccination.org/professional‐resources/practice‐ toolkit/facts.html 3. Adult Immunization Q&A adultvaccination.org/professional‐resources/practice‐ toolkit/faqs.html 4. Immunization Tracking Forms adultvaccination.org/professional‐resources/practice‐ toolkit/immunization‐tracking‐forms.html

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Recommended Adult Immunization Schedule—United States - 2013 Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. VACCINE 

19-21 years

AGE GROUP 

22-26 years

27-49 years

Influenza 2,*

50-59 years

60-64 years

≥ 65 years

1 dose annually

Tetanus, diphtheria, pertussis (Td/Tdap) 3,*

Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs

Varicella 4,*

2 doses

Human papillomavirus (HPV) Female 5,*

3 doses

Human papillomavirus (HPV) Male 5,*

3 doses

Zoster 6

1 dose

Measles, mumps, rubella (MMR) 7,*

1 or 2 doses

Pneumococcal polysaccharide (PPSV23) 8,9 Pneumococcal 13-valent conjugate (PCV13) Meningococcal 11,*

1 or 2 doses 10

1 dose 1 dose

1 or more doses

Hepatitis A 12,*

2 doses

Hepatitis B 13,*

3 doses

*Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster

Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967. Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400. Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at www.cdc. gov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 8:00 a.m. - 8:00 p.m. Eastern Time, Monday Recommended if some other risk factor - Friday, excluding holidays. is present (e.g., on the basis of medical, Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human occupational, lifestyle, or other indication) Services. No recommendation The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse-Midwives (ACNM).

Asplenia (including HIV infection ImmunoHeart disease, elective splenectomy CD4+ T lymphocyte compromising 4,6,7,10,14,15 and persistent chronic count conditions Men who complement (excluding human have sex lung disease, component chronic immunodeficiency < 200 ≥ 200 with men 4,6,7,10,15 deficiencies) 10,14 alcoholism cells/μL cells/μL (MSM) INDICATION  Pregnancy virus [HIV])

VACCINE 

Influenza 2,*

1 dose IIV annually

Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Varicella 4,*

1 dose Tdap each pregnancy

Kidney failure, end-stage renal disease, receipt of hemodialysis

1 dose IIV annually

Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs Contraindicated

Human papillomavirus (HPV) Female 5,* Human papillomavirus (HPV) Male 5,*

2 doses

3 doses through age 26 yrs

Zoster 6

Contraindicated

Measles, mumps, rubella (MMR) 7,*

Contraindicated

Pneumococcal polysaccharide (PPSV23) 8,9 Pneumococcal 13-valent conjugate (PCV13) 10 Meningococcal 11,* Hepatitis A 12,* Hepatitis B 13,* *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications) No recommendation

May 3-5 • San Francisco

1 dose IIV or LAIV annually

Chronic liver disease

3 doses through age 21 yrs 1 dose 1 or 2 doses 1 or 2 doses 1 dose 1 or more doses 2 doses 3 doses

Diabetes

Healthcare personnel

S U N D A Y

1 dose IIV or LAIV annually

These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older, as of January 1, 2013. For all vaccines being recommended on the Adult Immunization Schedule: a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/pubs/acip-list.htm). Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

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Recommended Immunizations for Adults If you are this age, Talk to your doctor or nurse about these vaccines:

19 - 21 years

22 - 26 years

Influenza (Flu)1

27 - 49 years

50 - 59 years

60 - 64 years

65+ years

Get a flu vaccine every year Get a Tdap vaccine once, then a Td booster vaccine every 10 years

Tetanus, diphtheria, pertussis (Td/Tdap)

Varicella (Chickenpox)

2 doses 3 doses

HPV Vaccine for Women

HPV Vaccine for Men3

3 doses

Zoster (Shingles)

1 dose

Measles, mumps, rubella (MMR)

1 or 2 doses

Pneumococcal

1 -3 doses

Meningococcal

1 dose

1 or more doses

Hepatitis A

2 doses

Hepatitis B

3 doses

Boxes this color show that the vaccine is recommended for all adults who have not been vaccinated, unless your doctor or nurse tells you that you cannot safely receive the vaccine or that you do not need it.

Boxes this color show when the vaccine is recommended for adults with certain risks related to their health, job or lifestyle that put them at higher risk for serious diseases. Talk to your doctor or nurse to see if you are at higher risk.

No recommendation

FOOTNOTES:

(Influenza vaccine) There are four different types of flu vaccines available—talk to your doctor or nurse about which flu vaccine is right for you.

(Tdap vaccine) Pregnant women are recommended to get Tdap vaccine with each pregnancy to increase protection for infants who are too young for vaccination but at highest risk for severe illness and death from pertussis (whooping cough).

(HPV vaccine) 3There are two different kinds of HPV vaccine but only one HPV vaccine (Gardasil®) can be given to men. Gay men or men who have sex with men who are 22 through 26 years old should get HPV vaccine if they haven’t already started or completed

the series.

(MMR vaccine) 4If you were born in 1957 or after, and don’t have a record of being vaccinated or having had these infections, talk to your doctor or nurse about how many doses you may need.

(Pneumococcal vaccine) 5There are two different types of pneumococcal vaccine: PCV13 and PPSV23. Talk with your doctor or nurse to find out if one or both pneumococcal vaccines

are recommended for you.

If you are traveling outside of the United States, you may need additional vaccines. Ask your doctor or nurse which vaccines you may need.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines

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May 3-5 â&#x20AC;˘ San Francisco

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Session #12: Sunday, May 5, 2013 | 10:00-11:00 am

Improving Diabetes Outcomes: Placing the Patient at the Center (Robert Carmichael)

Bo Greaves, MD and Chris Sadler, PA-C, CDE independent, community-based health education nonprofit county organization. He also developed a diabetes treatment center within St. Joseph Health Foundation that operated out of his medical group. He chaired the Diabetes Coalition of Sonoma County and developed and oversaw a proactive diabetes management program for all patients with diabetes admitted to Santa Rosa Memorial Hospital for Total Joint Replacement Surgery. Activity Description Using a team approach to teaching, Dr. Greaves and Mr. Sadler will focus their session on Robert Carmichael, recently diagnosed with type 2 diabetes and working to understand and manage his condition. This session includes discussion on how to integrate the patient into the care team. Learning Objectives At the end of this educational activity participants should be able to: - Identify and effectively address barriers to optimal patient-centered care in T2 diabetes. - Implement best practices for treatment of T2 diabetes, including use of oral and injectable agents, and insulin initiation and intensification. - Demonstrate effective communication skills and cultural competency in management of T2 diabetes. - Apply strategies for improving patient selfmanagement and overcoming patient resistance to change. Lyman “Bo” Greaves, past CAFP president and chair of our Diabetes Advisory Board, spearheaded the New Directions in Diabetes Care initiative for CAFP/ CAFP-F. He received his undergraduate degree from Johns Hopkins University and medical degree from the University of California, Davis. Dr. Greaves is currently medical director of Santa Rosa Community Health Center’s Round Barn Circle campus. He was president of Primary Care Associates, a 23 physician/eight nurse practitioner medical group with five offices in Sonoma County, CA. In 1995, Dr. Greaves developed a prototype of diabetes self-management classes identified though medical group claims data which grew into an

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Chris Sadler is affiliated with Diabetes and Endocrine Associates in La Jolla, California. He specializes in intensive insulin therapy using MDI and insulin pumps, management of type 2 diabetes and other endocrine disorders. Mr. Sadler obtained a master of arts degree from San Diego State University in San Diego, California, and a physician assistant certificate from Stanford University Medical Center-Foothill College Primary Care Associates Program in Palo Alto, California. In addition, he is a certified diabetes educator, an insulin pump trainer and preventive and rehabilitative exercise specialist. Author or co-author of several journal articles and abstracts on continuous glucose monitoring and other diabetes related subjects, Mr. Sadler has presented at local and national conferences on diabetes related topics. He also has extensive experience in clinical research. Mr. Sadler is past-president of the San Diego Association of Diabetes Educators. Faculty Disclosure: Dr. Greaves declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. Mr. Sadler declares that during the past 12 months he has consulted and/or received honoraria from Amylin/ Lilly, Amylin and Novo Nordisk. In compliance with its policy for Conflict of Interest identification, management and resolution, the CAFP’s Committee on Continuing Professional Development reviewed and approved this session. This session is supported by unrestricted educational grants from Novo Nordisk and Sanofi Aventis. 65th CAFP Annual Scientific Assembly

4/3/2013

Jointly sponsored by the CAFP and American Academy of Physician Assistants and supported by unrestricted educational grants from Novo Nordisk and Sanofi Aventis

2013| California Academy of Family Physicians

Faculty Lyman “Bo” Greaves, Jr, MD, FAAFP Medical Director Vista Family Health Center Santa Rosa, CA

Chris Sadler, MA, PA‐C, CDE Diabetes and Endocrine Associates La Jolla, CA

S U N D A Y

Faculty Disclosures • It is the policy of CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all of their continuing education activities. • The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP. • Dr. Greaves declares that in the past 12 months he has nothing to disclose. Mr. Sadler declares that during the past 12 months he has consulted and/or received honoraria from Amylin/Lilly, Amylin and Novo Nordisk.

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Learning Objectives After this session learners should be able to: • Identify and effectively address barriers to optimal patient‐centered care in T2 diabetes. • Implement best practices for treatment of T2 diabetes, including use of oral and injectable agents, and insulin initiation and intensification. • Demonstrate effective communication skills and cultural competency in management of T2 diabetes. • Apply strategies for improving patient self‐ management and overcoming patient resistance to change.

The Epidemic Rages On •

25.8 million people (8.3 percent of the US Population) affected by diabetes.

•

1 in 3 US adults could have diabetes by 2050 if current trends continue. Type 2 diabetes accounts for 90 to 95 percent of these estimated cases. (CDC)

•

Total cost of diabetes in the United States in 2007 is estimated at $218 billion (CDC) Centers for Disease Control, 2011 National Diabetes Fact Sheet

Falling Down on the Job Multiple studies show providers wait too long before advancing therapy • Kaiser Northwest study1‐ took between 26.5 – 35.1 months to change or add treatment • DAWN study2 ‐ Only Japan & India take longer than US physicians to initiate insulin 1Brown JB, Nichols GA, Perry A. The burden of Treatment failure in type 2 diabetes. Diabetes Care. 2004;27(7):1535-1540. 2Peyrot M, Rubin RR, Lauritzen T, et al; International DAWN Advisory Panel. Resistance to insulin therapy among patients and providers. Diabetes Care. 2005;28(11): 2673-2679

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Communication is Key! Reply by Brian (bsc) on October 2, 2012 at 8:24am

When I was first diagnosed, I thought the quality of my doctor was how technically competent they were … but I found I was dead wrong. I'd rather have a doctor who listens to me, understands my feelings and respects me as a member of the team. I'd much rather have a doctor who is empathic. www.tudiabetes.org/forum/topics/doctor-empathy-a-factor-in-diabetes-care

Meet Esther

Esther 64 yo female with T2 diabetes Metformin 1000 mg bid Struggles with weight, always hungry BMI ‐ 32 Recent A1C ‐ 8.7% Has irregular hours, eats at varied times, concerned about hypoglycemia when trying to lower A1C • Hypertension controlled on ACEI • Hyperlipidemia controlled on atorvastatin except elevated triglycerides (220 mg/dl) • • • • • •

May 3-5 • San Francisco

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We want to know Esther Key Questions • Who are you? What is your life like? • What is important to you? • What’s it been like, for you, having diabetes? • Any cultural issues?

Family & Friends

Care Team

Medication

ANTI‐HYPERGLYCEMIC THERAPY* • Glycemic targets ▫ HbA1c < 7.0% (mean PG ~150‐160 mg/dl [8.3‐8.9 mmol/l]) ▫ Pre‐prandial PG <130 mg/dl (7.2 mmol/l) ▫ Post‐prandial PG <180 mg/dl (10.0 mmol/l)

• Individualization is key: ▫ Tighter targets (6.0 ‐ 6.5%) ‐ younger, healthier ▫ Looser targets (7.5 ‐ 8.0%+) ‐ older, comorbidities, hypoglycemia prone, etc. ▫ Avoidance of hypoglycemia *ADA-EASD Position Statement: Management of Hyperglycemia in T2DM PG = plasma glucose Diabetes Care, Diabetologia. 19 April 2012

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Robert Carmichael, 58 years old, has just been diagnosed with type 2 diabetes. He is overweight (BMI 28) and has stage 1 hypertension. His LDL is 119 mg/dL. He experienced an anterior wall MI six months ago. According to the 2013 ADA Clinical Practice Recommendations, what goal would you set for his A1c:

0% 0% 0% 0%

1. 2. 3. 4.

<6.5 <7.0 <7.5 <8.0

0 of 350

ADA/EASD Position Statement: Managing Hyperglycemia in T2D

Glyburide Pioglitazone Glimiperide (Actos) (Humulin/Novolin) Glipizide

Sitagliptin (Januvia)

Exenatide (Byetta)

NPH

Saxagliptin (Onglyza) Linagliptin (Tradjenta)

Liraglutide Glargine (Victoza) (Lantus) Exenatide ER Detemir (Bydureon) (Levemir)

S U N D A Y

DPP4-I=DPP-4 inhibitor; FX=bone fracture; GI=gastrointestinal; GLP-1-RA=GLP-1 receptor agonist; HF=heart failure; SU=sulfonylurea; TZD=thiazolidinedione Inzucchi SE et al. Diabetologia. 2012;55(6):1577-1596

GLP-1 Choices • Liraglutide ‐ take once daily SQ ▫ 0.6 mg sq daily x 1 week ▫ 1.2 mg sq daily x 1 week ▫ 1.8 mg sq daily thereafter

• Exenatide – take bid 0‐60 min. prior to meal ▫ 5 mcg sq bid x 1 month ▫ 10 mcg sq bid x 1 month thereafter

• Exenatide ER ‐ take once weekly SQ ▫ Steady state achieved in 6‐8 weeks

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Shared Decision Making Esther Learns About Options

We Learn what that Patient Values

Together we figure out best treatment option

Motivational Interviewing: It is the patient’s plan, after all…

Esther’s Story

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Esther (3 months later) • 64 yo female with type 2 diabetes • Metformin 1000 mg bid, long acting GLP‐1 • Decreased appetite, lost 6 lbs • Recent A1C – 7.2%

How is Esther Doing? • Progress on trust of care team, and confidence that she can succeed • Still stressed, but has developed new responses, and feels happier in general • Happy about weight loss, and about increased energy • Is talking to the Health Committee at her church about starting a diabetes support group there

S U N D A Y

Social Media: Info & Support

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Smart Phone Apps

People Like Me

Family & Friends

Diabetes Education

Care Team

Medication

Behavioral & Cognitive

Community

Social Organizations

Esther (6 months later) • 64 yo female with type 2 diabetes • Metformin 1000 mg bid, long acting GLP‐1 • Decreased appetite, lost an additional 3 lbs • A1C Remains – 7.2% • Met with Diabetes Educator • 7 point glucose profile for 3 days

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7 point glucose profile

Polonsky WH,, et al. Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled noninsulin-treated T2 diabetes: results from the Structured Testing Program study. Diabetes Care. 2011;34(2):262-267

Step 1: Identify the primary glycemic abnormality • Look for hypoglycemia and resolve it first • Then look for and resolve fasting hyperglycemia • Then look and resolve postprandial hyperglycemia (excursions >50 mg/dL above fasting/preprandial blood glucose value)

S U N D A Y

Step 2: Determine how frequently the abnormality occurs • Determine when and how frequently the abnormality is occurring. • An abnormality that occurs frequently (2 out of 3 days) at the same time of day indicates a problem that needs to be addressed.

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Step 3: Determine potential causes, medication, behavior or both Common causes of hypoglycemia: • Medication – prescribed dosage too high; timing inappropriate • Behavior – taking medication incorrectly (wrong dose & timing); insufficient carbohydrate intake; excessive exercise. Common causes of fasting hyperglycemia: • Medication – prescribed dosage too low; timing inappropriate; different or additional medication that targets fasting hyperglycemia is needed. • Behavior – taking medication incorrectly (wrong dose & timing); failure to take medication.

Step 3 cont.: Determine potential causes, medication, behavior or both Common causes of postprandial hyperglycemia: • Medication – prescribed dosage too low; medication inappropriate; different or additional medication that targets postprandial hyperglycemia is needed. • Behavior – taking medication incorrectly (wrong dose & timing); excessive carbohydrate intake; insufficient exercise.

Step 4: Take Action After the cause or causes of the abnormality are identified, take action: • Medication: change dosage; change/add medication • Behavior: provide instruction on medication administration; provide education or refer to diabetes educator for counseling on appropriate behavior modification (diet, exercise, importance of adherence to medication regimen)

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7 point glucose profile

Adding Basal Insulin After discussing options – agreed upon adding basal insulin at HS to lower fasting BG to goal of <110

S U N D A Y

Shared Decision Making Esther Learns About Options

We Learn what that Patient Values

Together we figure out best treatment option

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Insulin Tritration Self‐monitored FPG (mg/dL) Titration: Increase in Insulin Dose 1 unit every day until fasting glucose < to goal

Basal insulin + GLP-1 • Adding basal insulin (detemir) to metformin and Liraglutide achieved an average A1C reduction of 0.5%, and average FBG reduction of 39 mg/dl • Low risk of hypoglycemia and there was no wt. gain • Long–term combined therapy with glargine and exenatide for up to 24 months in patients with inadequately controlled type 2 diabetes revealed reduction of A1C (0.7%) without significant weight gain or increased hypoglycemia DeVries JH, Bain SC et al. Sequential intensification of metformin treatment in T2 diabetes with liraglutide followed by randomized addition of basal insulin prompted by A1C targets. Diabetes Care July 2012 vol. 35 no. 7 1446-1454 Buse JB, Bergenstal RM, et al. Use of twice-daily exenatide in basal insulin-treated patients with T 2 diabetes: a randomized, controlled trial. Ann Intern Med. 2011;154:103–112

Esther

(3 months post insulin) • 64 yo female with type 2 diabetes • Metformin 1000 mg bid, long acting GLP‐1, glargine 20 units q HS • Weight—lost an additional 2 lbs • Recent A1C –6.5% • FBG 90‐110 mg/dl • 2 hr pc BG 118 – 176 mg/dl

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How is Esther Doing? • Feels great about her successes • Tracks her fitness activities every day • Tracks what she eats • Uses a smart phone app • Happy about continued weight loss, and about increased energy • Is the leader of a diabetes support group at her church

People Like Me

Family & Friends

Peer Support

Care Team

Neighborhood

Medication

Behavioral & Cognitive

Community

Workplace

Diabetes Education

Social Organizations

S U N D A Y

Esther’s Story

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Patient-Centered Care Shifting the Locus of Control Shared Agenda‐ Setting

Shared Decision‐ Making

Self‐ Management Support

Motivational Interviewing

Summary • Engage and partner with patients in chronic illness care – they are in charge! • Use motivational interviewing skills and concrete tools like action plans ‐ they can work. • Build primary practice teams that can support patients in self management‐ you cannot do this alone for a full panel of patients. • Combination therapies that maximize glucose lowering but minimize hypoglycemia and weight gain are desired in many patients with type 2 diabetes.

Thank You! Questions from Audience?

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Session #13: Sunday, May 5, 2013 | 11:30 am-12:15 pm

Cancer Screening in Family Medicine (Sarah Jones)

William O. Woo, MD

Activity Description The March 2013 issue of Consumer Reports featured an article about cancer screening test – and offered readers information on the test they need, and the tests they don’t. Are your patients asking? Learning Objectives At the end of this educational activity participants should be able to: - Implement cancer screening practice in the general patient population - Conduct shared decision-making conversations regarding cancer screening - Discuss with patient the cancer screening beliefs promoted by main stream media, and clarify questions they may have caused. Dr. Woo is a newly-board certified family physician and is currently completing his first year in practice at Kaiser Permanente in Anahiem, CA. He obtained his associates of science degree from Cypress College, followed by his undergraduate training at the University of Southern California. Dr. Woo attended medical school at Drexel University College of Medicine in Philadelphia, PA. He then went on to complete a Family Medicine residency at Kaiser Permanente in Orange County, CA where he was a chief resident. Dr. Woo was one of the graduates from the inaugural class of the CAFP’s CME Leaders Institute and is now serving on both the CAFP Board of Directors and Committee on Continuing Professional Development. Faculty Disclosure: Dr. Woo declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting.

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Consumerism In the Face of Cancer Screening William Woo MD CAFP ASA May 5, 2013

2013| California Academy of Family Physicians

William Woo MD • Practicing Physician, Family Medicine ▫ Kaiser Permanente Southern California

• Board Certified – Family Medicine • Dr. Woo has no relevant financial disclosures.

▫ No relevant personal financial holdings pertaining to topics discussed in today’s lecture ▫ Dr. Woo’s family does not have financial holdings pertaining to topics discussed in today’s lecture

Consumerism • It grows the economy • It Increases the variety and selection of goods and services, and

•It plagues the practice of medicine.

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Objectives 1. Familiarity and comfort with implementing cancer screening practices in the general patient population 2. Confidence in conducting shared decision making conversations regarding cancer screening 3. Understanding of cancer screening beliefs promoted by main stream media

Where did they get their info? • Dr. Oz said . . . ▫ I printed this out from WebMD ▫ I would like a referral for a full body scan to check for cancer ▫ My chiropractor said I should have this list of tests • My friends/family/person I know from work/[insert random person here] thinks I should get ovarian cancer screening. • Should I get screening for prostate cancer at the next Hockey game? ▫ ZERO Partners With NHL for Hockey Fights Cancer Awareness Month

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Breast Cancer • Most frequently diagnosed cancer in women in the United States excluding skin cancer • Second only to lung cancer as a cause of cancer deaths • 182,460 cases of invasive cancer - 2008 • 67,770 cases of in situ breast cancer – 2008 • 40,480 breast cancer deaths • Screening has remained at stable levels 20002010

Breast Cancer Screening • AFP update 2/15/2013 – AAFP recommendations. • Last USPSTF update 2009 • Recommends against BSE • Insufficient evidence for CBE • Insufficient evidence for Breast MRI • Routine biennial mammogram screening for women 50-74

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Breast Cancer Screening Comparison Screening Modality

AAFP

ACS

ACOG

USPSTF

BSE

Recommend s against

Counsel benefits and limitations

Breast selfawareness encouraged

Recommends against

CBE

Insufficient evidence

q 3 years2039, then annually

q 1-3 years 20 – 39, then annually

Insufficient evidence

MRI

Insufficient evidence

Annually for high risk

Insufficient evidence

MAMMO

Routine Biennial 50-74

Routine annual screening at age 40

Routine Biennial 50-74

What Do Patients Want? • Breast MRI ▫ ACS recommends its use in high risk patients ▫ No studies have evaluated MRI screening of average-risk women ▫ Can have a lower specificity than Mammo, could lead to higher bx rate and greater over diagnosis

• Clinical Breast Exam ▫ Sensitivity of 40-69% Specificity 88-99%

• Breast Self Exam

S U N D A Y

▫ Sensitivity 12-41%

Cervical Cancer • 6.6 cases per 100,000 women 2003-2007 • Age-adjusted mortality 2.4 deaths per 100,000 2003-2007 • Incidence rates by Race ▫ ▫ ▫ ▫

Hispanic (11.1 per 100,000) Black (10.0 per 100,000) Non-Hispanic white (7.4 per 100,000) American Indian and Alaska Native (7.8 per 100,000) ▫ Asian and Pacific Islander (7.3 per 100,000)

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Cervical Cancer Screening • USPSTF recommendations March 2012 • Women ages 21 – 65 with cytology every 3 years • Women ages 30 to 65 every 5 years with co-testing (cytology + HPV) • Recommends against screening for cervical cancer in women < 21. • Recommends against screening for cervical cancer in women > 65 who have had adequate prior screening and are not otherwise at high risk for cervical cancer

Colon Cancer Screening

What’s Changed?

We Are Doing Better

Adapted from US DHHS website, Health System Measurement Project

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AAFP Colon CA Screening Guidelines • All adults 50 years and older should be screened • Routine screening for colorectal cancer should continue until age 75 • Options for colorectal cancer screening include:

– Annual FOBT – Flexible Sig every five years (with or without FOBT) • USPSTF Recommends Flex Sig with highsensitivity fecal occult blood testing every 3 years – Colonoscopy every 10 years

Prostate Cancer Screening • The AAFP recommends against (PSA) screening for prostate cancer. (2012) • USPSTF May 2012 Recommendation Statement

– “The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect patients' preferences” – “Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients – “Community- and employer-based screening should be discontinued”

S U N D A Y

PSA Benefits • 5/1000 will die of prostate cancer without screening • 4-5/1000 will die of prostate cancer with screening • 0-1/1000 will not diet of prostate cancer because of screening

Adapted from data USPSTF Recommendation Statement 2012

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PSA Harm • At least 1 false-positive screening PSA test result • 110/1000 positive results – Most positive test results lead to biopsy – With BX up to 33% will have moderate or major bothersome SX

• 90% of diagnosed men are treated

– Large majority of the men being treated would do well without treatment – Substantial % of these men would have remained ASX for life. – 3/1000 Serious cardiovascular events, DVT or PE, Death – 29/1000 ED – 18/1000 Urinary Incontinence

Other Cancer Screening Reminders • Lung Cancer (2004) ▫ Insufficient evidence to recommend screening ASX persons for lung cancer with LDCT, CXR, sputum Cx, or a combination • Bladder Cancer (2011) ▫ Insufficient evidence to assess the balance of benefits and harms of screening for bladder cancer in ASX adults.

• Oral Cancer (2004) ▫ Insufficient evidence to recommend for or against routinely screening adults for oral cancer • Ovarian Cancer (2012) ▫ Recommends against screening for ovarian cancer in women • Pancreatic Cancer (2004) ▫ Recommends against screening for pancreatic cancer in ASX adults

Screening Rates

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Tips To Improve Screening Rates • Enthusiasm ▫ Patients perception of enthusiasm within Physician increased likelihood of mammography and (FOBT).

• Power of the physician patient relationship ▫ Latina women with high satisfaction in their healthcare relationship and trust in their providers were significantly more likely to have Mammogram

• High quality communication and strong relationship ▫ High levels of patient perception were associated with increase in screening rates for colonoscopy 16%

Shared Decision Making • Particular process of decision-making by the patient and clinician • Patient should: ▫ Understand risk or seriousness of the disease or condition to be prevented ▫ Understands the preventive service, including the risks, benefits, alternatives, and uncertainties ▫ Weigh his or her values regarding the potential benefits and harms associated with the service

S U N D A Y

Shared Decision Making: Challenges and Opportunities • Challenges: ▫ Consumerism  High Visibility tests  Tests of special individual importance

• Opportunities: ▫ Strengthens the patient provider partnership ▫ Allows providers to elicit the Pt’s primary concern

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Consumerism – All Is Not Lost

Consumer Reports • Article challenges the idea that more screening and early screening saves lives. • Not always better safe than sorry. ▫ Over Tx of harmless cancers/ Excessive workup of a false alarm

• The right screening tests can help you avoid dying ▫ Don’t underestimate the benefits of lifestyle changes

• Recommends screening for Cervical Cancer, Breast cancer, and colon cancer • Recommends against screening for cancer of the bladder, lung, prostate, ovaries, pancreas

Case Study • Marta, age 52, is Hispanic. • Lost both her parents in a car accident when she was teenager, and for 2‐3 years after their death drank and smoked marijuana heavily. While Marta no longer uses the substances, she still smokes cigarettes. • What are the recommended cancer screening tests? • What strategies would you use to improve compliance with these recommendations?

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• What recommendations would you give Marta when she patient requests Lung cancer screening due to her smoking hx. • What about a full body scan?

Case Study • Robert Carmichael, Camille’s husband, is 58, 40 pounds overweight, with high blood pressure, and a recent diagnosis of Type 2 diabetes. He travels at least twice monthly for his work with a technology company. • What cancer screening tests would you recommend for him?

S U N D A Y

• Robert inquires about prostate cancer screening. How do you go about conducting your shared decision making conversations with him?

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Summary • Know the recommendations ▫ Have talking points ready

• Engage your patients in shared decision making ▫ Elicit the pts concerns and values

• Don’t let consumerism ruin your cancer screening practices • Use these discussions to gently remind your pts to adopt healthy lifestyle changes.

References • U.S. Preventive Services Task Force, Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement Ann Intern Med. 2009;151:716-726 • Screening for Cervical Cancer: Recommendation Statement Ann Intern Med. 2012;156(12):880-891. • Triona, MT; Breast Cancer Screening Update, AFP Feb 15 2013;87(4):274-278 • Wilkins, T; Colorectal Cancer: A Summary of the Evidence for Screening and Prevention, AFP. 2008 Dec 15;78(12):1385-1392 • Colon Cancer Screening Rates Graph Accessed 3/25/13 from https://healthmeasures.aspe.hhs.gov/measure/25 • AAFP prostate cancer screening with PSA recommendations accessed 3/25/13 from http://www.aafp.org/online/en/home/clinical/exam/prostatecancer.html • Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement May 2012

• Sheppard, VB et al Are Health-care Relationships Important for Mammography Adherence in Latinas? J Gen Intern Med 23(12):2024–30 • Underhill ML, Kiviniemi MT; The association of perceived provider-patient communication and relationship quality with colorectal cancer screening. Health Educ Behav. 39(5):555-63, 2012 Oct • Goldsmith G, Chiaro C; Colorectal cancer screening: how to help patients comply J. FAM. PRACT.. 57(7):E2-7, 2008 Jul • MMWR; Cancer Screening – United States, 2010 Accessed 3/26/13 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6103a1.htm#fig • Consumer Reports magazine: March 2013 The cancer tests you need—and those you don't • Sheridan, SL et al; Shared Decision-Making About Screening and Chemoprevention: A Suggested Approach from the USPSTF, AHRQ Pub. No. 04-0529 December 2003

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Images • Mammogram machine ▫ By Ollirg; Dreamstime.com – Royalty Free

• Colonoscopy ▫ By Caraman; Dreamstime.com – Royalty Free

• Consumer Report’s Cover March 2013 ▫ Accessed 3/25/13 via

http://www.healthnewsreview.org/2013/01/consumer-reports-cover-

story-cancer-tests-you-need-and-those-you-dont/

Thank You! Questions from Audience?

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Cancer Screening Recommendations Breast Cancer USPSTF recommendations; 2009  

   

Biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation. Decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation. Current evidence is insufficient for screening mammography in women 75 years or older. Grade: I Statement. Recommends against teaching breast self‐examination (BSE).Grade: D recommendation. Current evidence is insufficient for clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement. Current evidence is for digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

Cervical Cancer USPSTF recommendations; 2012 

 



Recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. Grade: A Recommendation. Recommends against screening for cervical cancer in women younger than age 21 years. Grade: D Recommendation. Recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. Grade: D Recommendation. Recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high‐grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. Grade: D Recommendation. Recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years. Grade: D Recommendation.

Colon Cancer USPTF recommendations; 2008  248

Recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until 65th CAFP Annual Scientific Assembly



 

age 75 years. The risks and benefits of these screening methods vary. Grade: A Recommendation. Recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient. Grade: C Recommendation. Recommends against screening for colorectal cancer in adults older than age 85 years. Grade: D Recommendation. Evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. Grade: I Statement.

Evidence supported options for colorectal cancer screening:   

Annual FOBT Flexible sigmoidoscopy every 5 years with or without FOBT Colonoscopy every 10 years

Prostate Cancer USPSTF recommendations 2012 

Recommends against PSA‐based screening for prostate cancer.

Tips To Improve Screening Rates  

Enthusiastically discuss recommended cancer screening tests Strong communications combined with perceived pt satisfaction and trust in there providers increases likelihood of screening

Shared Decision Making     

Pts should understand risk and seriousness of the disease or condition to be prevented Understands the preventive service including the risks, benefits, alternatives, and uncertainties Pt’s values regarding the potential benefits and harms associated with the service should be assessed Shared decision making can strengthen the patient provider partnership When discussing requests for screenings that have insufficient evidence or that may harm the patient, be sure to elicit the patient’s primary concern and address it directly.

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Helpful Tools and Websites for Cancer and Cancer Screening: AAFP policy for a number of clinical preventive services:

Summary of Recommendations for Clinical Preventive Services – AAFP October 2012 http://www.aafp.org/online/en/home/clinical/exam/intro.html

USPSTF A‐Z Topic Guide Website of the most current USPSTF guidelines http://www.uspreventiveservicestaskforce.org/uspstopics.htm

Mammography Quality Standards ACT ‐ MQSA

Tool to find MQSA certified facilities http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm

Breast Cancer Risk Assessment Tool

Tool Designed by the National Cancer Institute and the National Surgical Adjuvant Breast and Bowel Project to estimate a woman’s risk of developing invasive breast cancer. http://www.cancer.gov/bcrisktool/Default.aspx

American Cancer Society http://www.cancer.org

World Health Organization

Information on international cancer data and screening efforts http://www.who.int/cancer/en/

American Congress of Obstetricians and Gynecologists http://www.acog.org/

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Session #14: Sunday, May 2013 | 12:15-1:15 pm

Restless Legs Syndrome—Causes, Consequences and Clinical Management (Sally Carmichael) Paul Doghramji, MD and Karl Doghramji, MD a member of the National Headache Foundation and Chronic Fatigue and Immune Dysfunction Syndrome Association. He was certified by the American Board of Family Medicine.

Activity Description The Brothers Doghramji have presented this interactive give-and-take session at the North Carolina and Georgia AFP meeting, getting ready for our stage. They will offer practical clinical and patient information for the screening, treatment and management of RLS. Learning Objectives At the end of this educational activity participants should be able to: - Describe the pathophysiologic basis of restless legs syndrome (RLS) and its practical considerations for differential diagnosis and treatment - Accurately diagnose patients with primary or secondary RLS based on patient history, physical and neurologic exam, comorbidities, and a comprehensive assessment of related impairments - Use evidence-based strategies to treat patients with RLS based on age, symptom severity, frequency of symptoms, and comorbidities - Evaluate the clinical and pharmacologic properties of current and emerging treatments for patients with RLS - Effectively monitor treatment responsiveness and restructure treatment accordingly in patients with RLS Paul P. Doghramji, MD, is cofounder of Brookside Family Practice and Pediatrics, a current affiliate of Pottstown Medical Specialists, in Pottstown, PA. He has also been Attending Physician in Family Practice, Chair of the Utilization Management Committee, and Physician Advisor at Pottstown Memorial Medical Center. Dr. Doghramji received his medical degree from Jefferson Medical College in Philadelphia and completed his residency in family practice at Chestnut Hill Hospital, also in Philadelphia. He is a fellow of the American Academy of Family Physicians, May 3-5 • San Francisco

His work on sleep medicine has been published in Postgraduate Medicine, the Journal of Clinical Psychiatry, INSOM Magazine, and the International Journal of Clinical Practice, as well as various websites including Medscape and Pri-Med. He is co-author of the textbook entitled “Clinical Management of Insomnia,” released January 2007 Karl Doghramji, MD is currently the Medical Director, Jefferson Sleep Disorders Center; Program Director, Fellowship in Sleep Medicine; Professor of Psychiatry and Human Behavior and Associate Professor of Neurology at Jefferson Medical College in Philadelphia. He attended Jefferson Medical College, completed his internal medicine residency at Presbyterian-University of Pennsylvania Medical Center, and his psychiatry residency at Thomas Jefferson University Hospital in Philadelphia. He is board certified in psychiatry and neurology. Faculty Disclosure: Dr. Paul Doghramji declares that in the past 12 months neither he, nor any member of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. Dr. Karl Doghramji declares that in the past 12 months he has served as a consultant for UCB and Elan, and owns stock in Merck. The educational planning staff from Asante, Christopher Ontiveros, declares that in the past 12 months neither he, nor any members of his immediate family, has had a relevant financial interest in corporate entities supporting this meeting. In compliance with its policy for Conflict of Interest identification, management and resolution, the CAFP’s Committee on Continuing Professional Development reviewed and approved this session.

S U N D A Y

This session, in cooperation with Asante Communications, is, is supported by an unrestricted educational grant from UCB.

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Jointly sponsored by the California Academy of Family Physicians and Asante Communications, LLC. Supported by an unrestricted educational grant from UCB, Inc.

Faculty

Karl Doghramji, MD

Paul P. Doghramji, MD, FAAFP

Professor of Psychiatry and Human Behavior Professor of Neurology Jefferson Medical College Director, Sleep Disorders Center Thomas Jefferson University Hospital Philadelphia, Pennsylvania

Family Physician Collegeville Family Practice Medical Director of Health Services Ursinus College Collegeville, Pennsylvania

Faculty Disclosures Karl Doghramji, MD Jazz Pharmaceuticals, Inc. (Consultant); Merck (Shareholder); Teva Pharmaceuticals, Inc. (Consultant); UCB, Inc. (Consultant)

Paul P. Doghramji, MD, FAAFP Cephalon, Inc. (Speakers’ Bureau); Horizon Pharma, Inc. (Advisory Board); Iroko Pharmaceuticals, LLC (Advisory Board); Merck (Advisory Board); Purdue Pharma L.P. (Speakers’ Bureau); Takeda (Speakers’ Bureau); UCB, Inc. (Advisory Board)

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Educational Objectives 1. Describe the pathophysiologic basis of restless legs syndrome (RLS) and its practical considerations for differential diagnosis and treatment 2. Accurately diagnose patients with primary or secondary RLS based on patient history, physical and neurologic exam, comorbidities, and a comprehensive assessment of related impairments 3. Use evidence-based strategies to treat patients with RLS based on age, symptom severity, frequency of symptoms, and comorbidities 4. Evaluate the clinical and pharmacologic properties of current and emerging treatments for patients with RLS 5. Effectively monitor treatment responsiveness and restructure treatment accordingly in patients with RLS 4

Restless Legs Syndrome

Assessment and Diagnosis in Primary Care Karl Doghramji, MD Professor of Psychiatry and Human Behavior Professor of Neurology Jefferson Medical College Director, Sleep Disorders Center Thomas Jefferson University Hospital Philadelphia, Pennsylvania

S U N D A Y

Restless Legs Syndrome Patient Descriptions It feels like I have water running underneath my skin

It burns and aches

It just makes me want to move It feels painful

It feels like I have a toothache in my leg My legs feel creepy, crawly, and tingly

It feels like I have worms or bugs crawling deep in my muscles It feels like electricity in my legs

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Diagnostic Features of RLS • U=urge to move the legs, usually associated with unpleasant leg sensations • R=rest induces symptoms • G=getting active (physically and mentally) brings relief • E=evening and night make symptoms worse

Trenkwalder C, Paulus W. Nat Rev Neurol. 2010;6(6):337-346.

IRLSSG Nonessential but Common Features • Family history – Prevalence in first-degree relatives is 3-5 times greater than in those without RLS

• • • • •

Response to dopaminergic therapy Periodic limb movements during sleep or wakefulness Variable clinical course Sleep disturbance Medical evaluation/physical exam reveals no abnormalities in primary RLS

IRLSSG, International Restless Legs Syndrome Study Group. Allen RP, et al. Sleep Med. 2003;4(2):101-119.

Most Troublesome Patient Complaints Sleep-Related Symptoms

43.4%

Uncomfortable Feeling in Legs

27%

Pain

21.4%

Inability to Stay Still/Urge to Move

11.8%

Inability to Get Comfortable

11.1%

Exhaustion/Fatigue

10.2%

Twitching/Leg Jerks

9.3%

Daytime Sleepiness

Not Stated

15.8% 0

Frequency, %

N=23,052 primary care patients from France, Germany, Spain, the United Kingdom, and the United States. Hening W, et al. Sleep Med. 2004;5(3):237-246.

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Symptoms Associated With RLS • Insomnia • Excessive daytime sleepiness • Cognitive impairment • Reduced quality of life

Symptom severity increases with frequency RLS, restless legs syndrome. Allen RP, et al. Sleep Med. 2010;11(1):31-37; Carskadon MA, et al. Sleep. 1986;9(4):519-524; Hening W, et al. Sleep Med. 2004;5(3):237-246; Jung KY, et al. Sleep Med. 2011;12(4):416-421; Kallweit U, et al. Eur Neurol. 2009;62(3):176-179; Silber MH, et al. Mayo Clin Proc. 2004;79(7):916-922; Swanson LM, et al. J Sleep Res. 2011;20(3):487-494; Winkelman JW, et al. Sleep. 2009;32(6):772-778.

Clinical Course of RLS Chronic and Progressive

Average current age (range) Average duration of illness (range) Average age first sought medical attention Family history Progression of symptoms

Age of RLS onset ≤20 (n=47) >20 (n=58) 57 years (28-42) 64 years (35-94) 46 years (13-75) 23 years (2-51) 32 years (8-72)

54 years (24-82)

81%

58%

•Severity

65%

68%

•Frequency Remissions >1 month

72% 37%

66% 16%

Walters AS, et al. Neurology. 1996;46(1):92-95.

S U N D A Y

Among your patients in primary care, have you ever diagnosed RLS? 0% 0%

1. Yes 2. No

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Misdiagnosis and Underdiagnosis of RLS in Primary Care 34.8

26.9

26.1

26.0

23.2

21.8

19.8

17.1

16.2

14.3

13.6

12.0

RLS

Diagnoses Attributed to RLS Symptoms

Neuropathy/ radiculopathy

Fatigue

CVD

Obesity

Arthritis

Nocturnal cramps

Anxiety

HTN

Insomnia/ sleeping

Back pain

Depressed mood/

Patients With RLS, %

CVD, cardiovascular disease; HTN, hypertension. N=551 primary care patients with RLS from France, Germany, Spain, the United Kingdom, and the United States. Hening W, et al. Sleep Med. 2004;5(3):237-246.

Screening Questions â&#x20AC;˘ Do you have any problems falling asleep? â&#x20AC;˘ Do your legs keep you from falling asleep? Single Question Screener When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? Yes No 100% sensitivity; 96.8% specificity

+RLS (n=112) 112 (100%) 0 (0%)

-RLS (n=452) 13 (2.9%) 439 (97.1%)

Ferri R, et al. Eur J Neurol. 2007;14(9):1016-1021.

REST Primary Care Study RLS Prevalence

Primary Care Patients, %

13.3 11.3

12 10 8

5.8

6 4 2 0

RLS At Any Frequency

RLS At Least Weekly

reporting at least twice-weekly RLS with moderate or severe impact on quality of life. REST, RLS epidemiology, symptoms, and treatment. n=3,655 primary care patients throughout the United States. Hening W, et al. Sleep Med. 2004;5(3):237-246.

RLS Sufferers*

*Subjects

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Prevalence by Gender and Age

Prevalence, %

RLS Patients (n=416) Women All Men

20-29

30-39

40-49

50-59

60-69

70-79

≥80

Age Range, years N=416 adults ≥18 years of age from France, Germany, Italy, Spain, the United Kingdom, and the United States. Allen RP, et al. Arch Intern Med. 2005;165(11):1286-1292.

Demographic Variables Race*

Geography

Gender

• Western Europeans, 9.72% • Northern Europeans, 8.44% • North Americans, 7.43% • Hispanics, 5.31% • Asians, 4.69% • Southeastern Europeans, 3.90%

• Differences reflect more than racial differences, as neighboring countries that share some genetic similarities also have significantly different RLS rates

• Females suffer RLS rates twice as high as their male counterparts across all populations, groups, and ages

• Middle Easterners, 3.29% • Africans, 0.00014%† majority of RLS studies have been conducted in Western Europe and the United States; †Cultural shunning is hypothesized for the calculated low prevalence rate, which was based on household interviews that lacked privacy among Africans. Allen RP, et al. Arch Intern Med. 2005;165(11):1286-1292; Yeh P, et al. Sleep Breath. 2011[Epub ahead of print].

*The

S U N D A Y

Primary vs Secondary RLS • Primary

– Occurs early in life peaking around 20 years of age – Family history increases chance that another family member has RLS 3- to 6-fold

22.7%

• Secondary

– Usually develops later in life – Symptoms are sporadic but regression of symptoms is slower and usually associated with another condition such as • Depression • CVD

77.3%

Primary RLS Secondary RLS N=300 RLS patients

Winkelmann J, et al. Sleep. 2000;23(5):597-602; Yeh P, et al. Sleep Breath. 2011[Epub ahead of print].

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Differential Diagnosis Differential Diagnosis RLS

Periodic limb movement disorder Peripheral neuropathy Peripheral vascular disease/claudication Sleep-related cramps Neuroleptic-induced akathisia Anxiety

Characteristics • Irresistible urge to move, usually legs (usual sensory component) • Most prominent at rest • Polysomnography finding; bursts of muscle activity during sleep • No motor or sensory component during wakefulness • Pain • Pain

• Partial relief with activity • Circadian pattern • Occasional “limb twitching” during sleep • Activity or rest • Evoked by activity

• Involve specific muscle groups • Partially relieved by stretching • Motor restlessness • Usually no sensory component • Day and night, sleep and wake • Motor and emotional • Typically generalized

• Generalized • Relieved with movement • Usually no sensory component • Typically no circadian variation

Garcia-Borreguero D, et al. BMC Neurol. 2011;11:28.

Restless Legs Syndrome and Depression • Depression and RLS are frequently comorbid – 2- to 4-fold risk of a depressive disorder in patients with RLS

• Dysregulation of CNS dopaminergic metabolism is potential pathophysiology to explain common cooccurrence • Many antidepressants promote or exacerbate RLS symptoms Hornyak M. CNS Drugs. 2010;24(2):89-98.

Restless Legs Syndrome and Cardiovascular Morbidity • RLS is associated with cardiovascular morbidity • Reduced dopamine, related increased sympathetic drive and vasoconstriction is the putative pathophysiologic link between RLS and cardiovascular morbidity (eg, HTN, HD, stroke) Venous and Arterial Pathology

HTN, HD, CVA

RLS/PLMS

Comorbidities

Sympathetic Activation

Dopamine Deficiency Iron Deficiency CVA, cerebrovascular accident; HD, heart disease; PLMS, periodic limb movements in sleep. Innes KE, et al. Sleep Med Rev. 2012;16(4):309-339; Walters AS, Rye DB. Sleep. 2009;32(5):589-597; Winkelman JW, et al. Neurology. 2008;70(1):35-42.

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Common Secondary Causes • Iron deficiency • End-stage renal disease – Prevalence from 20% to 62%

• Pregnancy – Approximately 1 in 4 pregnant women has symptoms, especially during third trimester, which usually resolves after delivery

• Neuropathy – Insufficient studies available to determine whether polyneuropathy increases the risk for RLS or what role neuropathy may play in the pathology of RLS

• Parkinson’s disease • Pharmacotherapy

Avecillas JF, et al. Cleve Clin J Med. 2005;72(9):769-770, 773-774, 776 passim; Hui DS, et al. Am J Kidney Dis. 2000;36(4):783-788; Neau JP, et al. Eur Neurol. 2010;64(6):361-366; Pourfar M, Feigin A. Neurology. 2009;72(11):950-951; Winkelman JW, et al. Am J Kidney Dis. 1996;28(3):372-378.

Medications Cause/Exacerbate Symptoms Drug Class

Medications

Antidepressants •Tricyclic antidepressants, amitriptyline •Lithium •Mianserin, mirtazapine, SSRIs •Metoclopramide, prochlorperazine Antiemetics Antihistamines •Sedative antihistamines Antipsychotics •Older neuroleptics (eg, haloperidol, perphenazine, levomepromazine) •Quetiapine, olanzapine, risperidone •Diltiazem, nifedipine, verapamil Ca2+-blockers •Phenytoin •Cimetidine H2-blockers SSRI, selective serotonin reuptake inhibitor. Partinen M. Sleep Med. 2007;8(Suppl 2):S19-S24.

S U N D A Y

Discussion Question • What are some of the common RLS misdiagnoses in primary care?

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Dopamine-Iron Connection

Putative Role in RLS Pathophysiology

• Iron is a cofactor of tyrosine hydroxylase, a ratelimiting enzyme in the synthesis of dopamine Rate limiting

Tyrosine Dopa

Tyrosine Hydroxylase

Dopamine Dopamine neuron

Dopamine Receptor

Receiving neuron

Jones R, Cavanna AE. Behav Neurol. 2012[Epub ahead of print]; Pereira JC, et al. Clinics (Sao Paulo). 2010;65(5):548-554.

Prevalence of RLS Among Anemic Patients and Iron Supplementation 30

100

80 IRLS Score

Patients, %

Iron (n=11) 21.6

60 40

Placebo (n=7) 24.8

23.0

34.4

14.5

†

10 5

6.3*

Anemic (n=64) Healthy (n=256)

Baseline

12 Weeks

vs healthy; †P<0.01 vs placebo. Scoring criteria on IRLS are: Mild (score 1-10); Moderate (score 11-20); Severe (score 21-30); Very severe (score 31-40). CSF, cerebrospinal fluid; IRLS, International Restless Legs Scale. Rangarajan S, D’Souza GA. Sleep Med. 2007;8(3):247-251; Wang J, et al. Sleep Med. 2009;10(9):973-975. *P=0.001

Initial Work-up Patient With RLS Symptoms Focused history and physical exam to exclude secondary causes/conditions that mimic RLS Review medications that may exacerbate RLS symptoms

Change medication or dosing regimen

Medications excluded Nonpharmacologic therapy/ Lifestyle interventions

Check iron studies Serum ferritin <50 µg/L

Serum ferritin >50 µg/L

Initiate iron therapy: FeSO4 325 mg tid + VitC 300 mg tid

Pharmacotherapy

tid, three times daily; VitC, vitamin C. Moyer DE, et al. J Fam Pract. 2009;58(8):415-423.

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Conclusions • RLS is prevalent in the primary care setting • RLS adversely affects sleep and quality of life • RLS displays overlapping symptoms with other morbidities commonly managed in primary care • The iron and dopamine systems are implicated in the pathophysiology of RLS

Restless Legs Syndrome

Initial and Ongoing Management Paul P. Doghramji, MD, FAAFP Family Physician Collegeville Family Practice Medical Director of Health Services Ursinus College Collegeville, Pennsylvania

S U N D A Y

Recognizing Sleep Problems • Screen patients with the following questions – How is your sleep? – Do you have trouble getting to sleep or staying asleep? – Do you get drowsy during the day or at inappropriate times?

• Medical history and physical— be attentive for – Possible coexisting psychiatric and medical illnesses that put patients at higher risk for sleep problems – Medications that cause or exacerbate RLS symptoms – Environmental factors that contribute to sleep problems

• Interview bed partner

Doghramji PP. Postgrad Med. 2004;116(6 Suppl Insomnia):14-22.

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Laboratory Evaluations in RLS • No laboratory tests are diagnostic of RLS • Obtain results for the following laboratory measures – – – –

Anemia Serum ferritin Transferrin saturation Comprehensive metabolic panel

• Hematocrit and blood glucose studies to check for kidney failure or diabetes Aurora RN, et al. Sleep. 2012;35(8):1039-1062; Cotter PE, O’Keeffe ST. Ther Clin Risk Manag. 2008;2(4):465-475; Sun ER, et al. Sleep. 1998;21(4):371-377.

Sally

Chief Complaint

I am having the hardest time sleeping lately. I toss and turn at night so much that I am unable to fall asleep. I think I have insomnia.

Sally

History and Physical Exam • Personal history – 78 years old – Widowed, 1 son – Currently lives in a senior community – Independent and active in church – Lives more than 8 hours from family

• Medical history – Depression diagnosed 1 year earlier

• Medication – Daily multivitamin – Ferrous sulfate, 150 mg daily – Fluoxetine, 20 mg daily

• Physical exam/vital signs normal for her age and medical history

What additional information would help with a differential diagnosis? 33

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Sally

Sleep/Wake Evaluation • Monday-Friday

• Saturday and Sunday

5:30 AM

Wake

9:30 AM

Leave home for church work

2:30 PM

Leave church work for home

5:30 PM

Dinner

10:30 PM

Go to bed

5:30 AM

Wake without alarm

10:30 PM Go to bed

• Patient reports symptoms occur almost daily – Difficulty falling asleep – Sluggish during the day

Good Sleep Hygiene

Minimize noise, light, and extreme temperatures

Maintain regular sleep/wake schedule

Discontinue caffeine 4-6 hours before bedtime

Exercise daily, but not within 4 hours of bedtime

Avoid nicotine, alcohol, and heavy meals before bedtime

≥8 hours/night in bed

Adapted from Blake DD, Gómez MH. Psychol Rep. 1998;83(3, pt 2):1175-1178; Bonnet MH, Arand DL. Sleep. 1995;18(10):908-911; National Heart, Lung, and Blood Institute Working Group on Problem Sleepiness; Bethesda, MD: National Institutes of Health; 1997.

S U N D A Y

RLS Treatment Primary RLS

Secondary RLS

Nonpharmacologic management

Treatment of primary disease

Alerting activities

Abstinence from caffeine, nicotine, and alcohol

Modify dosing of drugs that may enhance RLS

Iron replacement

Pharmacologic management Intermittent RLS

Daily RLS

Levodopa Benzodiazepines

Dopamine agonist

Low-potency opioids

Gabapentin

Chen PH, Cheng SJ. Int J Gerontol. 2009;3(4):197-203.

Refractory RLS Change to another dopamine agonist Change to gabapentin Add benzodiazepine, an opioid,or gabapentin

Change to high-potency opioid 36

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Restless Legs Syndrome

Behavioral and Lifestyle Modifications

Distraction techniques (eg, reading, needlework)

Change temperature (eg, bath, shower)

Exercise/Activity later in the day

Massage and leg compression

Relaxation therapy and stress reduction

Delay sleep time/ rise time

Acupuncture

Caffeine, nicotine, and alcohol avoidance

No formal studies on nonpharmacologic treatments are available, yet they are prudent to try before initiating pharmacotherapy

Aurora RN, et al. Sleep. 2012;35(8):1039-1062; Avecillas JF, et al. Cleve Clin J Med. 2005;72(9):769-770, 773-774, 776 passim; Restless Legs Syndrome Foundation. http://www.rls.org/Document.Doc?id=1919.

Cognitive Behavioral Therapy Quality of Life

28.6

23.4*

21.2

†

IRLS Total Score

QoL-RLS Score

40 30

Symptom Severity

25.9

19.1*

18.9*

End (8 weeks)

3-month Follow-up

10 0

Baseline

End (8 weeks)

3-month Follow-up

Baseline

*P<0.001 vs baseline; †P=0.001 vs baseline. IRLS Total Score, International RLS severity scale (0=no symptoms, 40=very severe symptoms); QoL-RLS, Quality of life in RLS (0=excellent, 54=very bad). N=25 (five men, 20 women; 15 medicated, 10 unmedicated) aged 56.1±12.3 years with subjective psychosocial impairment due to RLS participated in a weekly 90-minute program that integrated cognitive behavioral and acceptance-based mindfulness approaches. Hornyak M, et al. J Neurol Neurosurg Psychiatry. 2008;79(7):823-825.

Sally

Initial Treatment—Behavioral Modification • Try the following to alleviate symptoms close to bedtime – Massage – Hot or cold shower – Avoid symptom triggers (eg, caffeine, alcohol, medications) – Maintain good sleep hygiene

• Schedule a follow-up appointment How effective are nonpharmacologic treatments for RLS? How long after initiating nonpharmacologic treatment should follow-up occur? 39

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Sally

First Follow-up • Patient reports no improvement in restlessness and sleep problems • Laboratory evaluations Actual

Serum ferritin Serum iron TIBC

Reference Range

134.8 µg/L 73.7 µg/dL 377.2 µg/dL

15-200 µg/L 60-150 µg/dL 250-450 µg/dL

What serum ferritin levels should prompt consideration of iron supplementation as treatment? 40

Pharmacotherapy Dopaminergic Agents

Non Ergot-Derived Dopaminergics Pramipexole • FDA approved for the treatment of moderate to severe primary RLS

• Dosing: 0.125-mg tablets increased as needed to 0.5 mg 2-3 hours before bedtime • Adverse events*: fatigue, headache, nausea, somnolence

Ropinirole

• FDA approved for the treatment of moderate to severe primary RLS • Dosing: 0.25-mg tablets increased as needed to 4 mg 1-3 hours before bedtime • Adverse events*: dizziness, nausea, somnolence, vomiting

Rotigotine

• FDA approved for the treatment of moderate to severe primary RLS • Dosing: 1 mg/24 hours (transdermal patch) increased as needed to 3 mg/24 hours • Adverse events*: Application and installation site reaction†, asthenic conditions†, disturbances initiating and/or maintaining sleep†, headache, nausea, somnolence†

Levodopa

• Not FDA approved for RLS • Concern about daytime RLS augmentation, early morning rebound, and tolerance • Dosing: Typical doses of cardiodopa/levodopa are 25/100 mg to 100/400 mg in divided doses, given before bedtime and again, if needed, in the middle of the sleep period • Adverse events: Dry mouth, gastrointestinal symptoms, headache, somnolence

*Incidence >5% vs placebo; †Dose-related. Aurora RN, et al. Sleep. 2012;35(8):1039-1062; Mirapex® package insert, 2012; Moyer DE, et al. J Fam Pract. 2009;58(8):415-423; Neupro® package insert, 2012; Requip® package insert, 2009; Thorpy MJ. Neurology. 2005;64(12 Suppl 3):S28-S33.

S U N D A Y

Dopamine Agonists in Moderate to Severe RLS Short-term Efficacy

3-Month Responders* Placebo Active Placebo-Active Pramipexole Ropinirole

Rotigotine

51.2%

67.9%

16.7%

56.5%

73.3%

16.8%

40.9%

53.4%

12.5%

39.6%

59.5%

19.9%

N/A

6-Month Responders* Placebo

Active

Placebo-Active

N/A

46.7%

68.9%

22.2%

57.1%

80%

22.9%

45.5%

75.2%

29.7%

*Double-blind trials. Responders are patients who rated treatment as “much improved” or “very much improved” on the Clinical Global ImpressionImprovement (CGI-I) scale in which 1=very much improved and 7=very much worse. Bogan RK, et al. Mayo Clin Proc. 2006;81(1):17-27; Hening WA, et al. Mov Disord. 2010;25(11):1675-1683; Montplaisir J, et al. Mov Disord. 2006;21(10):1627-1635; Trenkwalder C, et al. J Neurol Neurosurg Psychiatry. 2004;75(1):92-97; Trenkwalder C, et al. Lancet Neurol. 2008;7(7):595-604; Walters AS, et al. Mov Disord. 2004;19(12):1414-1423; Winkelman JW, et al. Neurology. 2006;67(6):1034-1039.

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Dopamine Agonists in Moderate to Severe RLS Long-term Treatment

1-Year*

5-Year*

Responders†

Discontinued Treatment

Adverse Events‡

Pramipexole

94.8%

6.5%

None

N/A

Ropinirole

82.8%

19%

Nausea

25%

Application -site reaction║

Rotigotine

95.4%

Discontinued Treatment

Adverse Events‡

N/A

96%

39%

57%

None

Responders† Remitters§

*Open-label trials; †Responders are patients who rated treatment as “much improved” or “very much improved” on the CGI-I scale in which 1=very much improved and 7=very much worse; ‡>incidence ≥10% and related or possibly related to treatment; §Symptom-free (IRLS score of 0); ║Includes application site erythema, application site disorder, application site pruritus and other terms with lower frequency (eg, inflammation). Garcia-Borreguero D, et al. Sleep Med. 2007;(7-8):742-752; Oertel WH, et al. Sleep Med. 2008;9(8):865-873; Oertel W, et al. Lancet Neurol. 2011;10(8):710-720; Partinen M, et al. Sleep Med. 2008;9(5):537-541.

After initiating Sally’s treatment with a dopamine agonist, how long would you wait to assess treatment efficacy? 1. 2. 3. 0% 4. 0%

2 weeks 1 month 2 months 6 months

0% 0%

After initiating treatment with a dopamine agonist, how would you restructure treatment if the patient reports breakthrough symptoms during daytime? 0% 0% 0% 0%

1. 2. 3. 4.

Increase dose of the initial dopaminergic agonist Switch to a transdermal formulation Switch to a nondopaminergic medication Refer to a specialist

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65th CAFP Annual Scientific Assembly

Dopaminergic Agents Impulse Control Disorders • Reported in 7% to 17% of RLS patients using dopaminergic medication • More prevalent among patients using higher drug doses

Hypersexuality

1.4

Punding

2.1

Pathologic gambling

2.1

Compulsive shopping

3.6

Compulsive eating

4.3

Any ICB

7.1

0 2 4 6 8 RLS Patients Using Dopaminergic Agents, % Punding is compulsive fascination with and performance of repetitive, mechanical tasks, such as assembling and disassembling, collecting, or sorting household objects. DA, dopamine agonist; ICB, impulse control behavior; LEDD, levodopa equivalent daily dose; SD, standard deviation. N=140 RLS patients. Earley CJ, Silber MH. Sleep Med. 2010;11(9):807-815; Voon V, et al. BMC Neurol. 2011;11:117.

Nondopaminergic Agents Anticonvulsant Gabapentin •Not FDA approved for RLS

•Low-level evidence supports use for RLS therapy; pain relief with gabapentin supports consideration in patients with both RLS and pain

•Dosing: Average effective daily dose for treatment of RLS is 1855 mg •Adverse events: Ataxia, dry mouth, dizziness, fatigue, nausea, sedation, somnolence

Gabapentin •FDA approved for the treatment of moderate to severe primary RLS enacarbil

•Adverse events*: Dizziness, somnolence

Pregabalin

•Not FDA approved for RLS •Preliminary data show therapeutic efficacy, however, long-term follow-up and published experience for RLS is lacking

•Dosing: Optimal dose has not been identified •Adverse events: Somnolence, unsteadiness

Opioids

•Not FDA approved for RLS •Opioid data shows clinical effectiveness (low level of evidence) in treating RLS

•There is insufficient long-term evidence to make a recommendation for any one opioid •Adverse events can include potential for abuse and development or worsening of sleep apnea

•Dosing: 600 mg extended-release tablet once daily taken about 5 PM

* Incidence >5% vs placebo. Aurora RN, et al. Sleep. 2012;35(8):1039-1062; Horizant® package insert, 2012; Moyer DE, et al. J Fam Pract. 2009;58(8):415-423; Thorpy MJ. Neurology. 2005;64(12 Suppl 3):S28-S33.

S U N D A Y

Rebound and Dopaminergic Agents • Re-emergence of symptoms late in the sleep period or early morning as drug levels decline • Occurs more often with shorter-acting medications • Treatment restructuring may include – Reducing the dose of the provocative medication – Switching to an alternate dopaminergic medication with a longer half-life – Using a drug combination with a lower dopaminergic dose

Earley CJ, et al. Handb Clin Neurol. 2011;99:913-948; Cotter PE, O’Keeffe ST. Ther Clin Risk Manag. 2006;2(4):465-475.

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Augmentation and Dopaminergic Agents

• Increased lag before medication takes effect • Spread of symptoms to other limbs

Frequency of Augmentation, %

• Advance of symptoms to an earlier time • Intensification of symptoms • Reduced latency at rest to onset of symptoms

40 32 30

20 11

3 0 Levodopa Pramipexole Ropinirole (n=22) (n=90) (n-151)

Rotigotine (n=620)

Allen RP, et al. Sleep Med. 2011;12(5):431-439; Benes H, et al. Sleep Med. 2012;13(6):589-597; Earley CJ, et al. Handb Clin Neurol. 2011;99:913-948.

Discussion Question—Sally Treatment Restructuring

• How would you restructure treatment if the patient experiences rebound or augmentation?

Refractory RLS • Daily treatment of RLS associated with ≥1 of the following outcomes – Inadequate initial response despite adequate doses – Response that has become inadequate with time despite increasing doses – Intolerable adverse effects – Augmentation that is not controllable with additional earlier doses of the drug Refractory RLS

Change to gabapentin*

Change to another dopamine agonist or gabapentin enacarbil

*Off-label uses. Silber MH, et al. Mayo Clin Proc. 2004;79(7):916-922.

Add a benzodiazepin e, opioid, or gabapentin*

Change to a high-potency opioid*

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65th CAFP Annual Scientific Assembly

When to Consider a Sleep Consultation and/or Referral • When chronic sleep/wake complaints cannot be explained or remedied fully • Suspicion of narcolepsy and OSA • Unusual behaviors during sleep, with or without sleepiness Collaborative and continuous care of patients optimizes outcomes OSA, obstructive sleep apnea. Elliott AC. J Am Acad Nurse Pract. 2001;13(9):409-417; Goodie JL, et al. J Clin Psychol. 2009;65(3):294-304; Krakow B. Sleep Med. 2004;5(5):431-433; L’Estrange PR, et al. J Oral Rehabil. 1996;23(1):72-77; Pagel JF. J Fam Pract. 2008;57(8 suppl):s3-s8.

Conclusions • RLS is a neurologic disorder characterized by an irresistible urge to move the extremities • RLS diagnosis is frequently missed in clinical settings, is clinically established, and does not require objective testing. Use the URGE mnemonic • Patient assessment should exclude other disorders and establishment of subtype as primary or secondary • Treatment entails the effective management of comorbidities, promotion of proper sleep hygiene, and use of pharmacotherapy • If conservative measures are not effective, various pharmacologic formulations are available to individualize treatment

S U N D A Y

Audience Question & Answer Session

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Practice Management Seminar

Sunday, May 5, 2013 | 1:30-3:30 pm

Workshop: ICD-10 and what you need to know to change the way you code! Mary Jean Sage Activity Description Ms. Sage will walk participants through a series of exercises to assist them in preparing for the October 2014 launch of ICD-10! Learning Objectives At the end of the educational activity participants should be able to: - Implement ICD-10 codes and report them in all transactions for encounters or discharges on and after October 1, 2014. - Analyze systems and identifying the necessary changes that will need to be made to be compliant, - Identify internal work that needs to be completed, as well as work that will need to be done with external entities to prepare for ICD-10. Mary Jean Sage, founder of The Sage Associates, has extensive experience in the healthcare field that spans a period exceeding 20 years. During this period she has provided a wide range of management expertise to diverse groups of professionals in the healthcare industry. She is a nationally recognized speaker, consultant, and educator. As a health care management specialist, Ms. Sage assists health care professionals address and resolve management and business development issues. Her unique blend of administrative and clinical skills has earned her an enviable reputation as an expert in managed care operations and reimbursement management. She is recognized nationally for her expertise in coding and billing and the practical seminars and workshops she presents to healthcare professionals. She was instrumental in developing the Certified Medical Billing Associate program, which credentials medical billers and served as the initial Certification Director for the program. She currently serves as an advisor to a number of billing and coding publications. Ms. Sage received her degree in Business Administration from the University of Redlands, and her degree in Allied Health from Ferris State University. She is a credentialed Certified Medical Assistant (CMA-AC). She is a contributing author to CAFPâ&#x20AC;&#x2122;s monthly Practice Management eNewlsetter and the Coding and Billing monograph. Faculty Disclosure: Ms. Sage declares that in the past 12 months neither she, nor any member of her immediate family, has had a relevant financial interest in corporate entities supporting this meeting. The handouts for this session will be provided at the session.

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