Texas Family Physician, Q2 2018 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 2 2018

SPECIAL EDITION:

OVERDOSED The Opioid Epidemic In Texas And The Tools You Need To Fight Back

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INSIDE

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 2 2018

6 FROM YOUR PRESIDENT The opioid epidemic

By Larry Kravitz, MD

12 RESIDENT VOICE Leo Lopez III, MD: Advocacy matters

By Chris Crawford

30 PERSPECTIVE FPs should provide medication-assisted treatment for opioid addiction

Combating the opioid crisis

Family physicians are on the front lines of the fight to end the scourge of substance use disorder but they often lack the tools they need to be more effective. In this special edition of TFP, we publish a set of resources to help you address SUD in your community. By Jonathan Nelson

Courage on display at Community First Village

Meet Nancy Miller, a psychiatric nurse who cares for and lives among a community of formerly homeless people in a housing development in Austin.

Updated guidance for prescribing naloxone

Last year, the American Medical Association Opioid Task Force updated a guidance on prescribing naloxone.

Research: Employee health care utilization and the impact of job stress

By Sally P. Weaver, PhD, MD; Merideth Thompson, PhD; Dawn Carlson, PhD; and Marcus Butts, PhD

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 2 2018 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. OFFICERS president

Janet Hurley, MD

president-elect vice president treasurer

Javier “Jake” Margo, Jr., MD Mary Nguyen, MD

immediate past president

Tricia Elliott, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editors

Perdita Henry and Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Marcus Butts, PhD Dawn Carlson, PhD Chris Crawford Larry Kravitz, MD Leo Lopez III, MD Alan Schwartzstein, MD Merideth Thompson, PhD Sally P. Weaver, PhD, MD SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2018 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

By Janet Hurley, MD TAFP President

Rebecca Hart, MD

Amer Shakil, MD, MBA

parliamentarian

The supportive infrastructure primary care needs to combat the opioid crisis

TEXAS FAMILY PHYSICIAN [No. 2] 2018

earlier this year, I had the privilege of representing Texas family physicians at a conference sponsored by Superior Health Plan called “Changing the Paradigm in the Treatment of Chronic Pain and Substance Use Disorder in Texas.” As a middle-aged primary care physician who grew up in the era of “pain is the fifth vital sign,” I was frustrated by some comments made by legislators and health care policymakers, many of whom are not primary care physicians and have no idea what it is like trying to apply new pain guidelines to patients who are suffering. It is time to empower primary care physicians with the tools needed to manage these patients humanely and safely. The patients we worry the most about, who have had childhood traumas and diffuse pain syndromes, often take combination drugs like benzodiazepines and opiates, and are some of the hardest to treat. We are told by new CDC guidelines that we should try to minimize treatment with these drugs, yet these patients often have intense psychosocial needs that our medical communities are not equipped to address. Experiments done in other areas where physicians made a firm stance against ongoing prescribing have sometimes led to higher overdose deaths from illicit drug use.

While it is true that patients may be more functional and feel better overall if we successfully wean them off of their habit-forming medications, doing so without a supportive infrastructure may cause intense suffering and put patients at unnecessary risk. At this conference I learned that emotional trauma can alter the brain’s processing of many sensory stimuli, which may then lead to global pain syndromes and emotional distress that is additively disabling. Many patients are receiving anxiolytic benefit from opioids and are struggling with high levels of anxiety and inner turmoil due to past traumas. These patients need trauma therapy, yet many primary care physicians aren’t sure how to define that, nor do they know who provides that in their area. Communities often have licensed professional counselors and other behavioral health specialists who can provide some of these treatments. In the cover story of this edition of Texas Family Physician, you will find information on how to locate a variety of behavioral health specialists in your area with training to provide therapies most effective for treating post-traumatic stress disorder and anxiety, and who can assist in teaching patients coping strategies.

Reiner Consulting & Associates Practice ManageMent ServiceS

While many primary care physicians would prefer to refer these patients to addiction specialists, often this is not a practical reality for physicians practicing in smaller cities or rural areas. The lack of reliable patient transportation can also make referral unobtainable. In most areas of Texas, primary care physicians will need to continue being the medication prescriber, and additional educational tools are needed to support physician practices. One such resource is Project ECHO, which provides free education via a teleconferencing platform that primary care clinics can access from their own offices. Project ECHO has educational modules about addiction and pain management. Visit Project ECHO at https://echo.unm.edu/. Studies have shown that addiction management with buprenorphine can lead to fewer overdose deaths, fewer ER visits, less crime, and less pregnancy complications, yet most primary care physicians are not comfortable prescribing this. Project ECHO also has a module on buprenorphine management, which can serve as a free educational support group for any physician prescribing this medication. You can learn more about the legislative requirements related to buprenorphine prescribing on page 19. Naloxone has been shown to be a lifesaving drug during opiate overdose situations, yet many primary care physicians are not prescribing this to patients who are at higher than average risk. You can find more about naloxone on page 18. The state of Texas has mandated that Medicaid managed care programs in Texas have 25 percent of their total payments in 2018 associated with a value-based

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COMING SOON ON TAFP’S

CME SCHEDULE Annual Session & Primary Care Summit Nov. 9-11, 2018 Nov. 7-8: Business meetings and preconference workshops

Sheraton Arlington Hotel and Arlington Convention Center Arlington, Texas C. Frank Webber Lectureship & Interim Session April 5-6, 2019 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 7-9, 2019 La Cantera Hill Country Resort & Spa San Antonio, Texas 8

TEXAS FAMILY PHYSICIAN [No. 2] 2018

Physicians are called to alleviate suffering, be that emotional or physical. Let us not cast these patients away because they are difficult to treat, nor chastise good doctors who are facing impossible challenges due to the lack of supportive infrastructure.

alternative therapies to their patients with chronic pain. The group visit, where several patients come together at one time, provides limited acupuncture treatments, quiet time, support group strategies, pain education, and low-impact exercise such as yoga or tai chi. Guest instructors and exercise experts are invited and the cost is supported by the billing of CPT codes for each patient by the supervising provider. The fact that emotional trauma can cause physical pain is not a new problem. Psalm 38, written at about 1000 BC, helps to convey this: “…my whole body is sick because of my sins. My guilt overwhelms me— it is a burden too heavy to bear. My wounds fester and stink because of my foolish sins. I am bent over and racked with pain. All day long I walk around filled with grief.

arrangement. It is possible that some insurers may be willing to pay up-front in value-based payment arrangements to enable physicians to invest in pain management infrastructure. Superior Health Plan is exploring that opportunity with Texas Medicaid now. In the fee-for-service arrangement responsible for most primary care payments, there is an option to provide enhanced visits in a group visit arrangement. It is well established that alternative therapies such as yoga, tai chi, aquatic exercise, acupuncture, biofeedback, and mindfulness treatments are helpful in some patients with chronic pain, yet these treatments are not covered by insurance and may not be available in the patient’s community. At the opioid conference, I learned about a progressive practice in Austin that has leveraged the power of group visits using the fee-for-service payment model to provide

A raging fever burns within me, and my health is broken. I am exhausted and completely crushed. My groans come from an anguished heart.” Psalm 38: 3b-8 Many chronic pain patients tell me their “whole body hurts,” they are “racked with pain,” and “exhausted.” The primary source in some of our chronic pain patients is not a physical disease, but rather an “anguished heart.” Physicians are called to alleviate suffering, be that emotional or physical. Let us not cast these patients away because they are difficult to treat, nor chastise good doctors who are facing impossible challenges due to the lack of supportive infrastructure. It is time to work together to create real solutions for these patients.

AAFP CHRONIC PAIN MANAGEMENT TOOLKIT www.aafp.org/patient-care/public-health/pain-opioids.html

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ASK your patients if they use tobacco.

Martindale receives 2018 Gold-Headed Cane Award

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TEXAS FAMILY PHYSICIAN [No. 2] 2018

AM 9/9/10 9:18

Tim Martindale, MD, was presented with the Gold-Headed Cane Award by the McLennan County Medical Society at a banquet on Friday, April 13. This was the 19th year the member physicians of the McLennan County Medical Society nominated and voted for one of their colleagues to receive this award. Based on a tradition that originated in England in the 1600s, the qualifications of the recipient include professional standing, good citizenship, and personal integrity. The award is a symbol of respect, truth, culture, and art in the medical profession. Here in the United States, many larger cities have carried it on to honor an outstanding physician with a long history of commitment to quality medicine in their community. Martindale, a former pastor and journalist, attended the University of Houston and then the University of Texas in Austin before finishing medical school at UTMB in Galveston. He completed his residency in family medicine at the Family Medicine Residency Program in Waco, where he graduated as chief resident before joining Providence Hospital and opening his own practice while also serving as medical director of the Freeman Center for more than 10 years.

Tim Martindale, MD

In addition, Martindale has served as chief of staff for Providence Hospital, board chair of McLennan County Medical Education and Research Foundation, president of the Central Texas Academy of Family Physicians, member of the Waco Leadership Forum, and for two terms as president of the McLennan County Medical Society.

TAFP member wins ACOG Distinguished Service Award Janet Realini, MD, MPH, was recognized by the American College of Obstetricians and Gynecologists during their annual meeting. The College Distinguished Service Award is given to outstanding individuals who have made significant contributions to the College or the discipline of obstetrics and gynecology in government, in research, in teaching, or in direct patient care. “This award means so much to me because it recognizes the importance of family

planning and teen pregnancy Janet Realini, MD, MPH prevention to women’s health,” Realini says. “I am overwhelmed that ACOG would recognize a family physician for leading our collaborative work in Texas. Healthy Futures of Texas’ amazing team works with many local and statewide organizations to make a difference.”

Local TAFP chapters install new officers The Alamo Chapter of TAFP recently installed new officers. President, Linda May, MD; vice president, Stuti Nagpal, MD; president elect, Mary Anne Snyder, DO; secretary, Spencer Lewis, MD; treasurer, Mary Nguyen, MD; and immediate past president, Cecily Kelly, MD. The Harris Co. Chapter of TAFP also installed new officers. President, Lindsay Botsford, MD; vice president, Eric Lee, MD; president elect, Monica Clark-Reed, MD; secretary, Sherri Onyiego, MD; treasurer, Irvin Sulapas, MD; and immediate past president, Puja Sehgal, MD. Congratulations to all those assuming their new leadership roles.

UNT brings students into primary care clinical setting The University of North Texas Health Science Center has partnered with Catalyst Health Network to ensure their students receive training in the primary care clinical setting. “The agreement reinforces UNTHSC’s focus on education, research and the health care of the community,” said UNTHSC President Michael Williams, DO, MD, MBA. “It will also give students new opportunities to train in the clinical environment in which they will one day practice. “Catalyst not only aligns perfectly with UNTHSC’s values, it is the future of health care in North Texas,” Williams said. “This unique relationship embodies everything we do regarding our mission to create the health care providers of the future.” “Through this partnership, we will be able to accomplish more than either organization could do alone,” said Christopher Crow, MD, president of Catalyst Health Network. “UNTHSC is building the workforce of the future, and Catalyst is building the health care model of the future. Together we can shape the North Texas market to be a national leader in value-based care to help our communities thrive.”

Harris County Academy of Family Physicians hosts roundtable for medical students By Jean Klewitz HCAFP met for their third annual medical student roundtable on Tuesday, March 6, to host an open discussion on family medicine. The mission of the discussion is to dispel myths about family medicine often heard by students in academia. Members welcomed 28 medical students for dinner at Houston’s Baba Yega restaurant. It was an evening of frank questions and enlightening conversation in which even salary amounts were openly discussed. HCAFP President, Lindsay Botsford, MD, MBA, kicked off the presentation by telling the students that the goal was to break down barriers and “meet people who are actually doing family medicine.” Botsford moderated the nine-physician panel, which included physicians in academics, solo practice, and group practice. With the variety of careers represented on the panel, Botsford encouraged students to reach out after the discussion if they wanted a personal connection with someone who is practicing in a way they envision for themselves. Unable to represent the whole gamut of family medicine on the panel, Botsford said, “That’s the beauty of family medicine … we have so much diversity in what we do that we just couldn’t even represent it all here tonight.” Once the roundtable discussion was underway, one student asked what the physicians on the panel wished they knew about private practice when they were medical students. “Learn the business part of medicine,” solo practice physician, Rebecca Hart, MD, said. “They didn’t teach us this in medical school, so if you see CME or a class on that topic, I would highly recommend that you sign up for that.” Another student inquired about what it’s like to be in academics. Samuel Wang, MD, assistant director with the Memorial Family Medicine Residency Program at Physicians at Sugar Creek, answered: “If you’re going to be teaching, you have to be on the leading edge of medicine. You’re always learning. That’s one of the great things about family medicine, it’s a lifelong road of learning, which is exciting. It’s always fresh, there’s always something new to learn.” A student interested in obstetrics questioned the future of full-scope family medicine in urban areas. “It seems like people keep telling me it’s a dying breed, it doesn’t exist. It seems like the vast majority have moved away from that,” said Jason Johnston, a student at UT Health at Houston. “People sway us away from that kind of training.” The panel assured the students in the room that are still many doctors all over the country that practice full-scope family medicine, explaining that while it’s rare to find in a big city, it’s not a dying breed. Eric Lee, MD, with Baylor College of Medicine was met with applause when he said half of his residency class of eight still practice full-scope family medicine including inpatient care five years after completing their training. Additionally, the students and the panel discussed telemedicine, fellowship opportunities, behavioral health training in residencies, and salary expectations. The HCAFP Medical Student Roundtable is a perfect example of how local chapters of TAFP can and are working to inspire the next generation of family physicians by engaging medical schools and students. If your local chapter is doing something similar, be sure to let us know here at TAFP headquarters.

www.tafp.org

Photo courtesy of the TEXAS MEDICAL ASSOCIATION

WHY PHYSICIAN ADVOCACY IS IMPORTANT

MEMBER NEWS

By Leo Lopez, III, MD During the 2017 Texas legislative session, I spent time with TAFP at the State Capitol in Austin, appreciating the depth, scope, and importance of physician advocacy. In my time as a medical student and resident, I’ve watched health policy debates evolve. I’ve watched them triumph from inception to implementation. I’ve watched them fall in committee at the behest of a deluge of lobbying efforts and special interests. As these important issues revolving around clinical practice, graduate medical education, and access to health care are debated, the relative silence of the physician voice is impressive. While many outstanding physician leaders make selfless sacrifices to protect patient and physician interests, the gross physician influence in advocacy and health policy is severely impoverished. Coupling my time with TAFP and my clinical experience as a resident, it comes with little surprise that physicians suffer burnout at alarming rates, are dissatisfied with administrative burdens, resist mounting regulations, and struggle with insecurity in the ever-evolving zeitgeist of the U.S. health care system. My colleagues and I inherited a culture of medical practice that engenders a defensive approach to clinical medicine, leading to excessive documentation and a “CYA” mindset. I’ve often felt as though a lawyer or insurance executive or bureaucrat lurks over my shoulder, ensuring I’ve checked the requisite boxes, or have performed the satisfactory physical exam maneuvers. I’ve been conditioned to be chiefly concerned with which insurance my patient has, as this will dictate the medication, health service, or imaging study accessible to them. On several occasions, I’ve spent more time filling prior authorizations and waiting on hold for a peer-to-peer appeal for a medical service than I have at the bedside with my patient. This culture is in stark contrast with the practice of medicine I envisioned during the infancy of my training. Non-clinician forces utilized public policy to transform medicine, disproportionately, into an administrative career field. If we hope to take back our beloved, ancient discipline, stand for justice for our patients, and create a thriving environment for clinical practice, we must stand in solidarity and become active, relentless advocates on issues of health policy. 12

TEXAS FAMILY PHYSICIAN [No. 2] 2018

Athens FP installed as TMA president In May of 1948 at the Texas Medical Association’s annual meeting at Houston’s historic Rice Hotel, a group of general practitioners decided to organize an association in Texas to affiliate with the recently formed American Academy of General Practice. The event marked the beginning of TAFP. Seventy years later at TMA’s annual meeting now known as TexMed, a family physician who calls himself “an old country doc” became TMA president. Douglas Curran, MD, of Athens, Texas was sworn in as president of the nation’s largest medical society at the JW Marriott Hill Country Resort in San Antonio on May 19, 2018. He says his top priorities during his term will be to improve patient care in Texas and to increase access to that care for all Texans. “I feel very humbled by this opportunity to serve the patients of Texas physicians as well as protect and preserve the integrity of our profession,” Curran said in a TMA release. “The opportunity to serve as president of this great organization will allow me to speak from the heart about the profession I love and our commitment to improve the health care of all Texans.” Curran practices full-scope family medicine at Lakeland Medical Associates and at UT Health Athens. For nearly four decades, Curran has served as a fierce advocate for the patients and physicians of Texas. He played a leading role in the passage of Texas’ groundbreaking medical liability reforms, fought for sweeping patients’ rights reforms including holding managed care companies accountable for their actions, championed legislation to improve the Children’s Health Insurance Program and Medicaid, and

fought to ensure patient safety throughout the health care system. He has been active in TMA, TAFP, and AAFP, serving on numerous committees and in various officer roles. He is the immediate past chair of the TMA Board of Trustees and a member of the TMA Select Committee on Medicaid, CHIP, and the Uninsured. He is a past president of TAFP and a past winner of TAFP’s Family Physician of the Year award. He represented Texas as a delegate to the AAFP Congress of Delegates and served on the AAFP Commission for Governmental Advocacy. In June of 2017, Curran spoke to TAFP about his plans for his term as TMA president in a Member of the Month interview. “As far as where I think TMA is headed, it’s in a direction to improve the quality of care patients get,” he said. “Right now, we have access issues for Medicaid patients and enormous access issues for the working poor, we must address those. I will work on the areas of how we get better access to health care for all Texans. “I also want to work on better and fairer payment for all physicians. I think as alternate payment models come out, it’s going to give us an opportunity to change how we pay doctors. … My time will be spent being sure patients get the best they can get, in terms of quality and having adequate access to care, and for physicians, I want less hassle and a more appropriate payment model.” Curran should get his chance to focus on these topics. He will be in office during the preparation for and the duration of the 86th Texas Legislature. Here at TAFP, we know TMA couldn’t be in better hands.

When I first met Nancy Miller, she was just another nurse at the hy write about courage in medicine now? Simply table. Shift on. Shift off. She would not see herself as any different because we are witnessing an erosion of ethics, truth, than anyone else there in scrubs. She treats patients as they are. She science, and altruism in our society. Not that the world doesn’t project good or bad or say they are trying to manipulate us. has become a vast Sodom and Gomorrah, but we are They are broke, and we care for them as best as we are able. We fix seeing more amplified abandonment of idealism in what we can, without judging. We take care of their burden on socifront of us daily, and I have found myself more and more challenged ety. We are managers of this particular human community chaos. It to find public leaders embracing selflessness. It is more tempting to is our assignment. It should be done with humanity and practicality. abandon ideals when society doesn’t seem to value them anymore. So Dispassionate and compassionate at the same time. let us look back on an era where Washington, D.C. was once referred to as “Camelot” and idealism was the dream of the entire American realm, and let us decide together to still be courageous. THE HOMELESS The idea for John Kennedy’s 1955 Pulitzer Prize winning collection Medical care for the homeless. The problem haunts us. It’s hard of essays, “Profiles in Courage,” was perfect. The young Senator Kento get our heads around it. It gnaws at the edges of a doctor’s grand nedy prepares for a future of perspective of health care. statesmanship and service by Save $5 on a generic med here delving back to find beacons and avoid an unnecessary lab that could light his way fortest there; and yet the next ward in government. day the homeless show up in Maybe we don’t want to the ER and spend $30,000 on laud too many accolades on pancreatitis from drinking President Kennedy. “Profiles alcohol. Why do we even try? in Courage” may well have Because it turns out there been ghostwritten by others. are answers. Nancy Miller, RN, And Kennedy himself was is part of an answer. clearly quite imperfect. It is I’m going to talk about generally agreed that the man Austin, Texas, and you can think misused steroids, amphetabout your own city. In 2016, amines, and antibiotics while Austin had a little over 2,000 in the White House. homeless people at any given Though we may distance moment; 1,300 in shelters; 800 ourselves from the man himon the street. Twenty-two perself, I would still embrace the cent are chronically homeless. concept of Kennedy’s proposal: Twenty percent are children. that we remind ourselves of Fourteen percent are veterans. examples of selfless commitForty-five percent have a current By Larry Kravitz, MD ment in hopes of finding the mental health problem. In the same within us. And so I offer last six months, 63 percent have this profile in courage, which been to the ER (average $1,400), involves facing the impossible 20 percent have been taken to monster of caring for the homeless. It is a case of bringing courage a mental health hospital ($1,500/day), 40 percent have used an ambulance to a task where there is often little hope for success, and little vision ($880), and 33 percent have been hospitalized ($4,800/day). The health that anything will ever change. care expense staggeringly decreases once a homeless person is housed.

COURAGE IN MEDICINE

A PROFILE

Community First Village

NANCY IN THE ICU

COMMUNITY FIRST VILLAGE

On weekends, I work in an indigent psychiatric hospital; four floors full of depression, psychosis, substance abuse, anxiety, and despair. Behind an unbreakable Plexiglas barrier, we sit at a table in the nursing station of the third floor psychiatric ICU. There’s always a swaying body staring at us, mumbling or chanting, sometimes banging, sometimes pleading, sometimes singing, sometimes crying, and all psychotic. Here we handle all those people at the periphery of our lives. The guy standing on the street corner screaming obscenities as the cars go by. The drunk who got hit in the middle of an expressway. The woman who jumped off a bridge. The guy who called in a threat to kill the president. Most of them drift through a revolving door of homelessness and hospitalization. When they are wandering aimlessly behind the window across from the nursing station, they are not evil, racist, ungrateful, criminal, irresponsible, stupid, or abusive. Pathetically, they’re just psychotic. And if they end up here, the system simply failed.

Two years ago, Nancy Miller and her husband became one of 17 missional families. She picked up from her comfortable, large suburban Westlake home, and moved into a tiny trailer at Community First Village, becoming a resident in a 27-acre community in East Austin with affordable, permanent housing for the chronically homeless. Alan Graham is one of the founders of Mobile Loaves and Fishes, the organization that built this community. He described the idea in a December 2017 Austin Monthly article: “My model simply came from looking back at spiritual leaders over 2,000 years and what they do. Mother Teresa chose to go live in the bowels of Calcutta, India. Francis of Assisi gave up extraordinary wealth in order to go live and be amongst the lepers. And the population we’re dealing with are the most despised outcasts of our community — the chronically homeless. The men and women who are stereotyped as drug addicts, alcoholics, crack addicts, glue sniffers, prostitutes, gamers, hustlers.”

www.tafp.org

More about Community First Village. There are 140 residents at any given time. There is some rent. Everybody does some work. That work is nominal — maybe not what you or I call work. Twenty residents have left. Of those, eight went to their families; eight went to jail (weapons or substance abuse). Currently, two dozen are active alcoholics. Some are still on meth and crack — yes, they are. Some are chronic psychotics. All have PTSD of course, rape, assault, and other horrors, as you can imagine. Despite best efforts, the population is still preyed upon by criminal elements. How do they handle danger? They dial 911, same as anyone else. They do have aggression reduction training for staff. Generally, the police love Community First Village, as the alternative for many of these people is constant runins with law enforcement. The village now has a trailer rehab facility, and a trailer hospice, too. There is a public health clinic three days a week. An average dwelling is 180 square foot, as per the city minimum requirement, basically one room, for a cost of about $25,000. The dwellings have electricity only. Plumbing, cooking, and laundry are at communal buildings. Food is grown in the gardens. There’s an outdoor movie theater, a small store, an art studio, a machine shop, a bed and breakfast (imagine that), and social science internships with universities. Housing on 24 more acres will open soon.

Just for the record, there’s more to her “leap” to the homeless village. “It’s a pie chart,” she says, and faith is just one piece of the pie. For Nancy, living in the village is egosyntonic; it is in harmony with who she is. “The population is attractive to me.” Although there is no precedent in the U.S. for what they are building at Community First Village, the prospect of being a pioneer wasn’t what enticed Nancy. She was drawn by what she calls the “creativity of maintenance,” working out how to keep things going, or as she says: “Figuring ways to keep the plate spinning on the pole.” Nancy felt the need to pay back. I hear that a lot from volunteer faculty for medical schools as well. “Someone taught me,” they say, “and I was thankful, so I wanted to pay back.” It’s so universal. What is that emotion, the “pay-back” emotion? Why is that such a big piece of our medical motivational pie? How does she deal with moments of doubt and adversity? What were her disappointments? “I thought I would be doing more.” The lesson of medical courage is that, in the end, you must look in the mirror and face how all the phenomenal energy that you threw to the task didn’t really do that much. What was the scariest thing? “Immersing myself in the people. … Fear of harming them, being pointless, or being rejected.” It’s funny to think about being scared of rejection by the homeless. But this is their community. And Nancy Miller is a suburban do-gooder. The homeless can see right through that part of her. It’s worked out. They have made peace with that. How does she deal with boundaries between herself and the homeless? Money boundaries? Social boundaries? One goal in medicine is to practice with enough warmth that patients yearn to cross boundaries. And part of the strength and the drain of medicine is having firm but warm boundaries. It’s a challenge. “It’s new every day,” Nancy says.

Here we handle all those people at the periphery of our lives. The guy standing on the street corner screaming obscenities as the cars go by. The drunk who got hit in the middle of an expressway. The woman who jumped off a bridge. The guy who called in a threat to kill the president.

BECOMING NANCY AND THE NATURE OF COURAGE As Nancy says, “Maybe it’s built on previous steps.” Her story starts as a nurse married to a doctor with five children in an upscale suburb. She began training for nursing pastoral visits and then went for a masters in counseling. Next, she left nursing for a private practice in counseling. Then divorce happened after 30 years of marriage, along with a neck injury and spine surgery. Painful time passed. She married again to a cardiac nurse. Eventually she was back working, transitioning to psychiatric nursing. Then she and her husband moved to Community First Village. These are how the dots connect. What do I want to say about the nature of courageous choices? Which events on that timeline required the most courage? Rank ordering them, I think the divorce took the most courage. This was the hardest time in her saga, the time that summoned the most courage and strength. Devoting your life to the homeless may take courage. Putting yourself and your family back together after divorce, common though it may be, is a harder act of courage. But women like Nancy do that every day. Everyday family courage is more challenging than any ethical medical courage. Nothing we do in medicine matches the courage we must muster to weather family stress all the time. That’s the twist to consider. 14

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FINALE John Kennedy’s book explored courage. For now, let’s not say that Nancy Miller, our muse in this endeavor, is courageous. In the end, she would never be comfortable with that. It’s just where her life ended up. But go ahead and be like Nancy anyways, in any way you can. Is this courage? You can’t always get perspective when you’re immersed in your commitments. Yet Nancy does show us a path to extraordinary acts; and that there is a journey in our everyday lives to something that is both accessible and exceptional.

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TEXAS FAMILY PHYSICIAN [No. 2] 2018

OVERDOSED TOOLS AND RESOURCES TO HELP FAMILY PHYSICIANS COMBAT THE OPIOID EPIDEMIC BY JONATHAN NELSON

in 2016, 2,799 texans died due to drug overdose. In 2015, more than 52,000 people died of an overdose in the United States and more than half of those involved opioids. The problem is widely considered a national epidemic and although Texas ranks 48th among states in opioid deaths, the state is home to four of the country’s worst cities for opioid abuse rates. Texarkana, Amarillo, Odessa, and Longview make the top 25 at numbers 10, 13, 15, and 17, respectively, according to a 2016 report by Castlight Health, Inc. Opioid prescriptions have dropped dramatically since 2013 and the use of prescription monitoring programs across the country has increased significantly. Still the number of deaths continues to climb. According to a report from the Kaiser Family Foundation, heroin and illicit synthetic opioids like fentanyl are now responsible for more overdose deaths than prescription medications. Changing prescribing practices alone won’t stop the scourge of the nation’s opioid epidemic. Patients desperately need access to high quality, evidence-based treatment.

AFP reports that 90 percent of patients in need of addiction treatment services do not have access to appropriate therapies, like medication-assisted treatment. AAFP and the American Medical Association have joined forces to call on all payers to remove barriers to treatment for substance use disorder. “We urge family physicians to become certified in providing medication-assisted treatment,” AAFP President Michael Munger, MD, said in a statement. “Family physicians are uniquely qualified to meet the medication management and whole-person care that MAT requires. But in order to expand access to MAT, we must have universal policies that end barriers such as prior authorizations that delay or can essentially deny care for those who need it most.” In Texas, the Health and Human Services Commission is implementing strategies to combat opioid use disorders. As part of the federal 21st Century Cures Act, the agency received a grant of $27.4 million to be used for prevention, training, outreach, treatment, and recovery support services. HHSC estimates the funds will directly help 14,000 people over a two-year period. The project is called the Texas Targeted Opioid Response and its core strategies include increasing access to care and support, reduction of service gaps within the continuum of care, and increasing public awareness through education and outreach. State agencies, health systems, and nonprofit organizations from coast to coast are involved in similar efforts but if we are to stem the scourge of overdose deaths, family physicians on the front lines of primary care must actively help close the treatment gap for those afflicted with addiction and work to prevent opioid addiction by changing the paradigm of chronic pain treatment. In this edition of Texas Family Physician, we present a set of resources to help members combat the opioid crisis.

AMA opioid task force issues updated naloxone guidance By Chris Crawford

Physicians are increasingly prescribing naloxone in the fight against the opioid abuse crisis. During the first eight weeks of 2017, the number of naloxone prescriptions written by physicians increased 340 percent compared with the same period in 2016. Also during that time, the number of physicians prescribing naloxone increased 475 percent compared with the previous year. To aid in the response to this public health scourge, the AMA Opioid Task Force — to which the AAFP belongs — has released an updated resource family physicians can use for guidance when co-prescribing overdose drug naloxone with opioid medications. Search for “Naloxone Saves Lives” at www.aafp.org. “The opioid epidemic continues to take thousands of lives in this country,” said Jennifer Frost, MD, medical director for the AAFP Health of the Public and Science Division. “While family physicians work with their patients to prevent opioid misuse and overdose, naloxone is potentially life-saving for those patients who remain at risk. This (opioid task force) resource encourages clinicians to

AAFP’s magazine Family Practice Management published a helpful article in its November/December 2014 edition entitled “How to Monitor Opioid Use for Your Patients With Chronic Pain” by Stefani Hudson, MD, and Leslie Wimsatt, PhD. The article describes how with some simple tools, physicians can establish a written policy and a systematic process to prescribe opioids safely and securely. Access the article at:

www.aafp.org/fpm

PHYSICIAN PRESCRIBING GUIDELINES FOR CHRONIC PAIN Clinical practice guidelines to improve the way opioids are prescribed help physicians and health systems make sure patients receive effective treatment for pain while helping prevent misuse, abuse, and overdose. The gold standard may be the CDC Guideline for Prescribing Opioids for Chronic Pain.

www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm It is specifically designed to give guidance on prescribing opioid pain medication for patients 18 and older in primary care settings. The guideline is focused on treating pain outside of active cancer treatment, palliative care, and end-of-life care. AAFP officially affirmed the value of the CDC guideline in April 2016. A list of the key recommendations from AAFP’s perspective can be found on AAFP’s website.

www.aafp.org/patient-care/clinical-recommendations/ all/opioid-prescribing.html

TEXAS PRESCRIPTION MONITORING PROGRAM You probably already know about this and likely you already use it, but just in case, you can check into your patients’ prescription history by registering for an account with the Texas Prescription Monitoring Program, PMP Aware. As of September 2019, physicians in Texas will be required to use the Texas Prescription Monitoring Program administered by the Texas State Board of Pharmacy. The program allows physicians and pharmacists to examine a patient’s prescription history when considering prescribing or dispensing potentially addictive or dangerous pharmaceuticals. Texas is currently one of only about a dozen states that doesn’t require physicians to use a prescription monitoring program, but the number of doctors using the program in the state is already on the rise. As the law is currently written, physicians will have to look up a patient’s prescription history before prescribing opioids, benzodiazepines, barbiturates, or carisoprodol. Doctors will not be required to run checks on patients who have cancer or are in hospice care. If you’re not already registered, you can establish an account at:

https://texas.pmpaware.net 18

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consider co-prescription of naloxone and offers guidance about when this is most appropriate.” The updated resource recommends family physicians and other clinicians consider these factors when determining whether to co-prescribe naloxone to a patient and/or their caregivers: • Does the patient’s history or a state’s prescription drug monitoring program show that my patient is on a high opioid dose? • Is my patient on a concomitant benzodiazepine prescription? • Does my patient have a history of substance use disorder? • Does my patient have an underlying mental health condition that might make him or her more susceptible to overdose? • Does my patient have a medical condition, such as a respiratory disease, sleep apnea or other comorbidities that might make him or her susceptible to opioid toxicity, respiratory distress or overdose? • Would my patient be able to aid someone who is at risk for opioid overdose? In the AMA’s Aug. 24 “Advocacy Update,” Patrice Harris, MD, MA, chair of the AMA Opioid Task Force, said: “We know that naloxone — by itself — will not reverse the nation’s opioid epidemic, but it is a critical component that saves lives and provides a second chance.”

More naloxone co-prescribing considerations According to the task force’s newly updated naloxone resource, family physicians who are trying to determine whether to co-prescribe naloxone should also consider discussing with patients the risk for and symptoms of opioid overdose, the potential stigma associated with opioid use disorder, the broader issue of treating substance use disorder, and appropriate training to deal with an overdose. Additional benefits that co-prescribing naloxone offers include reducing emergency department visits and helping patients become more aware of the potential hazards of opioid misuse. The task force document also referenced a study published online Sept. 20, 2016, in the journal Substance Abuse that found that co-prescribing naloxone for patients at risk for overdose doesn’t increase the liability risk for practices. Specifically, the study stated that the legal risk associated with prescribing naloxone is no higher than that associated with prescribing any other medication and, in many cases, is lower. “Additionally, laws in a majority of states provide explicit legal protections for providers who prescribe or dispense naloxone, in many cases extending this protection to prescriptions issued to friends, family members and others,” the study said. Source: AAFP News, Aug 28, 2017. © 2017, American Academy of Family Physicians.

The AMA also hosts an End the Epidemic microsite featuring more naloxone resources. Go to www.end-opioid-epidemic.org/naloxone/.

REFERRAL RESOURCES FOR ADDICTION SPECIALISTS AND OTHER BEHAVIORAL HEALTH PROVIDERS Often you know you need to refer a patient to an addiction specialist or a therapist of some sort to provide more specialized counseling and treatment, or you may need to send someone to inpatient rehabilitation. But finding the right specialists and rehabilitation centers is not easy in our fragmented health care system. This becomes much more difficult in rural communities. Connecting mental health resources with primary care is a perplexing problem that we must begin to solve if we are to address the prevalence of chronic diseases linked to behavioral health. Texas Health and Human Services contracts with 39 local mental health and two behavioral health authorities to deliver services across the state. That’s a good place to start when looking for mental health resources in your community.

https://hhs.texas.gov/services/mental-health-substance-use You can search for your local mental health authority by county, city, or by ZIP code.

http://dshs.texas.gov/mhservices-search/ Outreach, screening, assessment and referral centers are located in the state’s local mental health authorities across the 11 HHS Regions of Texas. Access the list and a mapping app for different kinds of services around substance use disorder on the Texas Department of State Health Services website:

www.dshs.texas.gov/sa/OSAR/

The American Society of Addiction Medicine has a number of resources to help find addiction specialists in your community. According to ASAM, “Addiction specialists are addiction medicine physicians and addiction psychiatrists who hold either subspecialty board certification in addiction medicine from the American Board of Preventive Medicine, subspecialty board certification in addiction psychiatry from the American Board of Psychiatry and Neurology, board certification in addiction medicine from the American Board of Addiction Medicine, or a Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association.” Go to the Patient Resources department of their website at www.asam.org and look for “How to find an addiction specialist?” You’ll find a link to the searchable ASAM Member Directory plus a number of other referral resources for finding addiction specialists near you.

www.asam.org/resources/patient-resources

MEDICATION-ASSISTED TREATMENT MAT is one of the most effective treatment options available for people with substance use disorder. There are MAT protocols for opioid use, alcohol use, and smoking. They use a combination of medications, counseling, and behavioral therapies to provide a whole-patient treatment. Methadone, naltrexone, and buprenorphine comprise the three medications indicated for opioid addiction. The federal Substance Abuse and Mental Health Services Administration hosts lots of information about MAT as well as the registration processes necessary to become a certified MAT provider. Visit the SAMHSA Medication-Assisted Treatment page to get started.

www.samhsa.gov/medication-assisted-treatment www.tafp.org

“WE URGE FAMILY PHYSICIANS TO BECOME CERTIFIED IN PROVIDING MEDICATION-ASSISTED TREATMENT. FAMILY PHYSICIANS ARE UNIQUELY QUALIFIED TO MEET THE MEDICATION MANAGEMENT AND WHOLE-PERSON CARE THAT MAT REQUIRES. BUT IN ORDER TO EXPAND ACCESS TO MAT, WE MUST HAVE UNIVERSAL POLICIES THAT END BARRIERS SUCH AS PRIOR AUTHORIZATIONS THAT DELAY OR CAN ESSENTIALLY DENY CARE FOR THOSE WHO NEED IT MOST.” — MICHAEL MUNGER, MD AAFP PRESIDENT 20

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AAFP, other groups issue joint principles on opioid crisis Organizations call for congressional action to fight the epidemic By AAFP News Staff

AAFP teamed up with five other medical organizations to release guidance titled “Addressing the Opioid Epidemic: Joint Principles,” which is intended to inform congressional policies addressing the nation’s epidemic of opioid use disorder, or OUD. The other organizations that adopted these principles are the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association. Together, the groups represent more than 560,000 physicians and medical students. Among other things, the joint principles call on Congress to adopt policies that recognize OUD as a chronic disease of the brain that requires comprehensive treatment. They also urge policymakers to implement solutions that focus on families grappling with other serious substance use disorders as they take steps to address the immediate opioid crisis. “As a society, we need to ensure that people struggling with opioid use disorder — and this includes family members as well as patients — have access to comprehensive care,” said APA President Altha Stewart, MD, in a group statement. “Just like people with any other chronic illness, these patients must have coverage for treating a chronic brain disease. The doctors who treat them must be able to respond quickly during relapses and to provide ongoing care management without administrative delays that can lead to emergencies, inpatient care or other highcost treatment.” The joint principles call for a public health approach to SUDs that aims to reduce stigma while striving to ensure comprehensive pain management for patients. They also offer specific guidance on expanding access to treatment and increasing research into SUD prevention and treatment.

Methadone is an opioid agonist that helps prevent withdrawals. It must be dispensed daily in a specially regulated clinic. Naltrexone is a non-addictive opioid antagonist that blocks the effects of other narcotics. It can be dispensed from an office as a daily pill or a monthly injection. Buprenorphine is the first pharmaceutical treatment for opioid dependency that can be dispensed in physician offices and it has shown significant success in helping patients. It is an opioid agonist/antagonist that blocks other narcotics while helping to prevent withdrawal symptoms. It is taken as a daily dissolving tablet, a cheek film, or as a six-moth implant. According to SAMHSA: “When patients and physicians were surveyed by SAMHSA about the effectiveness of buprenorphine, they reported an average of an 80 percent reduction in illicit opioid use, along with significant increases in employment, and other indices of recovery.”

Emphasizing that an SUD is a chronic disease of the brain that can be effectively treated, the principles document calls for a variety of legislative and regulatory approaches to tackling this public health issue. Reduce the administrative burden associated with providing patients effective treatment. The current process of obtaining prior authorization for services and/or dispensing medications for an OUD is burdensome and delays access to life-saving care, the document notes. “When patients seek treatment for opioid use disorder, they need to get it now,” said AAFP President Michael Munger, MD, of Overland Park, Kansas, in the group statement. “They can’t wait until the doctor has obtained prior authorizations for services or for dispensing medications. We’re pleased some insurers have lifted prior authorizations for medication-assisted treatment, but we need to see more progress in order to minimize delays and increase the time physicians can spend with their patients.” Align and improve financing incentives to ensure access to evidence-based OUD treatment. Protecting Medicaid’s viability and maintaining its current financing structure, among other points, can help improve access to OUD treatment. “Persons with low income who are struggling with opioid use disorder must have access to Medicaid coverage,” said ACP President Ana María López, MD, MPH, who called for extending coverage to adults in nonexpansion states and maintaining Medicaid’s existing financing structure without caps or other changes. “Equally important, policies should mandate that Medicaid and Medicare pay for comprehensive medication-assisted treatment at the same rate they pay for other chronic illnesses,” she added. Incentivize more health care professionals to treat SUD. A critical component to stopping the opioid epidemic is making sure there are enough physicians to help treat those with SUDs in need, the principles contend. “We must ensure that patients have access to health professionals who can meet their needs,” said the APA’s Stewart. “An estimated 2.1 million Americans suffer from untreated SUDs. If we’re going to have a strong behavioral health workforce, our policies must provide incentives, such as education loan forgiveness, for those who provide care in underserved areas.” Advance research to support prevention and treatment of SUDs. Additional research is needed to inform optimal treatment to combat the opioid crisis, the principles note.

Texas has 16 state-funded opioid treatment service locations for indigent patients. In 2016, 5,381 people with opioid use disorder were admitted to state-funded treatment, but only 785 received MAT. Studies show medication-assisted treatment, or MAT, cuts all-cause mortality due to substance use disorders by more than half. Currently only 85 licensed providers of methadone practice in the state and only about 1,200 providers are certified to prescribe buprenorphine. So how do you get certified to prescribe buprenorphine? Physicians must qualify for a physician waiver under the Drug Addiction Treatment Act of 2000, or DATA 2000. To qualify for the waiver, a physician must: • be licensed under state law; • be registered with the Drug Enforcement Administration to dispense controlled substances;

“One of the most important elements of preventing and treating substance use disorders is understanding the safety and effectiveness of alternatives to opioid medications,” said ACOG President Lisa Hollier, MD. “Many of today’s nonopioid pain relief options are contraindicated for use during pregnancy. The National Institutes of Health must have the tools and flexibility to support innovative research on alternatives to opioids and appropriate opioid prescribing to treat pain without triggering addiction.” Address the maternal-child health impact of the opioid crisis. Increasing access to evidence-based treatment for pregnant and parenting women will improve maternal and child outcomes. “Parental substance use has a significant impact on child health and well-being,” said AAP President Colleen Kraft, MD, MBA. “More than a third of children entering foster care do so at least in part because of parental substance use. However, the science tells us that we can often better address the needs of affected families by providing access to evidence-based treatment for the whole family. “We need policies that support access to familial treatment and prevent unnecessary foster care placements when children can remain safely with their parents, including effective implementation of the Family First Prevention Services Act of 2017.” Continue to provide comprehensive pain management for patients. Although fighting the opioid epidemic is the priority, the principles recognize that physicians still need to help manage their patients’ long-term pain. “It’s vitally important that we take care of patients suffering from chronic pain, who are the most common recipients of opioid medications,” said AOA President Mark Baker, DO. “While our policymakers focus on preventing opioid misuse, they also must ensure that patients suffering debilitating, chronic pain have access to the most appropriate treatment.” Ensure a public health approach to SUDs by addressing childhood stress, access to naloxone, and fair and appropriate treatment for individuals in the criminal justice system and pregnant women. “Opioid use disorder is a public health crisis, and our policies must take a comprehensive public health approach to it,” Munger said. “With that focus, we can avoid long-term, adverse health consequences from children who suffer from trauma associated with a family member who has an untreated opioid use disorder. “We will save lives by providing targeted distribution of naloxone in the community. And we can prevent relapse and death among former inmates who had inadequate SUD treatment during their incarceration.” Source: AAFP News, June 13, 2018. ©2018, American Academy of Family Physicians.

• agree to provide buprenorphine treatment to no more than 30 patients at any one time within the first year of certification, (after the first year, physicians can apply to treat up to 100 patients at a time); • achieve qualification by training or certification. SAMHSA requires physicians to take an eight-hour buprenorphine waiver training course to achieve qualification and there are a number of places to go for that training. AAFP has a partnership with the Providers Clinical Support System for Medication Assisted Treatment. You can register and perform the training on the PCSS-MAT website for free, and you’ll also find a plethora of tools and resources for treating patients with opioid use disorders there.

https://pcssnow.org

[cont. on 22] www.tafp.org

AAFP: Fix physician payment to stem opioid epidemic By AAFP News Staff

An important starting point for addressing the nation’s opioid misuse epidemic is the creation of payment models that allow physicians to spend more time with patients and ensure they are appropriately compensated for services tied to substance abuse, the AAFP recently told a Senate committee. In February 2018, the Senate Finance Committee asked medical organizations for suggestions to address the epidemic, and the AAFP responded on Feb. 14 with a detailed letter that described how restrictive insurance policies and administrative burdens associated with nonpharmacologic treatment are hindering care for patients dealing with substance use disorders. “It is unfortunate that the payment and regulatory framework for physician practices has reduced face-to-face time with patients, making it more difficult for physicians and patients alike,” the AAFP wrote in the letter, which was signed by Board Chair John Meigs, MD, of Centreville, Alabama. Exacerbating the problem are the restrictions payers place on mental health care that family physicians are trained to provide. “Unfortunately, payment for primary care office visits with a mental health diagnosis code has traditionally been discounted or proscribed by private insurance, Medicaid and Medicare,” the letter stated. “Many man-

[cont. from 21] The American Society of Addiction Medicine offers a waiver training course in multiple formats.

www.asam.org/education/live-online-cme/waiver-training The American Academy of Addiction Psychiatry also offers a course covering legislation, pharmacology, safety, patient assessment, and more.

www.aaap.org/education-training/mat-8-hour-waiver-training The Project Extension for Community Healthcare Outcomes, or Project ECHO, is a learning and guided-practice model in which expert teams use videoconferencing technology to teach physicians in remote areas. The project began and is still largely housed at the University of New Mexico School of Medicine. The first project focused on treatment of kidney disease but the model is now used to expand clinical expertise across a wide range of diseases, including opioid use disorder. For a few more months, Project ECHO is hosting a set of interactive learning opportunities funded by a grant from the Health Resources and Services Administration that results in a certificate of training completion from ECHO and the American Society of Addiction Medicine. The program ends on August 31, 2018.

https://echo.unm.edu/nm-teleecho-clinics/opioid/ 22

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aged care plans do not pay family physicians for the provision of mental and behavioral health care, even though family physicians are frequently in the position to diagnose, treat, and provide the needed care.” The letter suggested that Medicaid and Medicare payment incentives could be used to reduce costs associated with opioid use disorder and other substance abuse treatment and to support appropriate co-prescribing of naloxone. The AAFP pointed out to the committee that although guidelines — including one from the CDC that the AAFP affirmed — support nonpharmacologic treatment for low back pain, for example, such treatment faces barriers from public and private insurers. “It is currently easier to write a prescription for opioids than to prescribe nonpharmacologic treatment,” the letter stated. In addition, more educational materials are needed to help patients who expect a prescription to accept nonpharmacologic treatment. The letter also warned the committee against “one size fits all” approaches to educating physicians about opioids. Family physicians already are committed to “fine-tuning their ability to prescribe opioids appropriately and effectively,” the AAFP said, noting that members completed more than 141,000 CME credits on this topic in 2016 alone. “The AAFP continues to believe educating physicians is an important tool, but to be impactful, the education must be designed to address needs and gaps of the learners,” the letter stated. The committee also should consider ways to improve the interoperability of state prescription drug monitoring programs, and the AAFP noted its support for a national prescription database. Source: AAFP News, Feb. 27, 2018. © 2018 American Academy of Family Physicians.

AAFP CHRONIC PAIN MANAGEMENT TOOLKIT AAFP offers an extensive set of tools and resources for combating the opioid epidemic through its Chronic Pain Management Toolkit, available at www.aafp.org. According to AAFP, “The toolkit helps family physicians identify gaps in practice flow, standardize evaluation and treatment of chronic pain patients, and facilitate conversations on pain and treatment goals, as well as identify and mitigate risk.” It includes an action plan, pain inventory, work questionnaire, patientphysician medication agreement, opioid risk tool, and links to external resources, AAFP articles and issue briefs. There you can also find CME webcasts on opioid addiction treatment and the Academy’s position paper, “Chronic Pain Management and Opioid Misuse: A Public Health Concern.” And don’t forget about the trove of patient information you can mine at familydoctor.org. From the main toolkit page, you’ll find links to at least four articles for patients on chronic pain, opioid addiction, prescription drug abuse in the elderly, and the safe use, storage and disposal of opioids.

www.aafp.org/patient-care/public-health/pain-opioids.html Opioid addiction and the death and despair it brings seem an almost intractable problem, and ending this epidemic will take the combined and sustained actions of all facets of society. Family physicians on the front lines of care have an integral role to play in this effort. We hope these resources assist you as serve your community.

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RESEARCH

Support for this project included a grant from the Texas Academy of Family Physicians Foundation.

Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

GOLD LEVEL Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White

Employee health care utilization and the impact of job stress Sally P. Weaver, PhD, MD Family Medicine Residency Program, Waco, Texas Merideth Thompson, PhD Utah State University, Logan, Utah Dawn Carlson, PhD Baylor University, Waco, Texas Marcus Butts, PhD University of Texas at Arlington, Arlington, Texas

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Introduction The United States spent $3.0 trillion on health care in 2014.1 Approximately $2.1 million per year per employer is spent on pain-related health care and around 13 percent of the U.S. workforce experiences pain-related work loss during any given two-week period.2, 3 Considering the large health care costs for businesses today, there is a need for more research that focuses on work-related predictors of chronic disease, chronic pain, and health care utilization.4, 5 Investigation into the relationships between work stressors and health is severely limited.5, 6 It is known that workplace demands and psychological experiences can produce changes in health.7 The research regarding work stressors and health, however, is almost exclusively focused on self-reported health outcomes.8 Exploring verified health care utilization through data directly obtained from patients’ health records is critical to seek answers to questions regarding work stressors and health care utilization (actual patient diagnoses, medications prescribed, number of office visits, etc.). This study intends to address this omission in the literature. We contend there are three major workplace stressors that contribute the most to psychosocial stress at work: job demands, relational aspects within the work context (abusive supervision), and relational aspects outside of work (work-to-family conflict). How these factors are related to objective health

outcomes (prescriptions for chronic illness or pain medications and the number of visits an employee makes to see a medical professional) is to be explored.

Methods Sample and procedures Participants were patients at four public health clinics in Central Texas. Field administrators were hired and trained to approach individuals in the waiting room of the health clinics and ask them if they wanted to complete a short survey. Similar procedures were adopted to request participation from clinic employees. In addition to completing the survey, patients were asked for permission to access their electronic health records maintained by the clinic. Participants were pre-screened to ensure they were employed, had a supervisor, and lived with at least one other person. Of the 2,218 people approached in person or employed by the clinic, we obtained 343 completed surveys with a signed consent form for a response rate of 15.5 percent. Each participant’s unique medical record number was used to extract health utilization data (i.e., medical diagnoses, medications, and number of clinic visits) from the clinic system’s EHR from the time of survey administration (November 2013) to 12 months afterward (November 2014). Some individuals did not utilize clinic health care during this 12-month time period and were excluded from the study further www.tafp.org

Table 1: Sample survey questions Measures

References

Example of question types

Job demands

Demerouti, Bakker, Nachreiner, & Schaufeli (2001)9

“I am asked to do an excessive amount of work”

Abusive supervision Mitchell and Ambrose (2007)10

“My supervisor puts me down in front of others”

Work-to-family conflict Matthews, Kath, & Barnes-Farrell (2010)11

“I have to miss family activities due to the amount of time I must spend on work responsibilities”

Burnout

Shirom (1989)12

“I feel physically drained”

Table 2: Demographics of study population Demographic variables Gender

Male 19% Female 81%

Race/ethnicity

38% Hispanic, 21% Caucasian, 29% African American

At least one dependent child

75%

Average number of hours worked per week

37.4

Average number of years at current job

4.5

Education

47% college degree 46% high school diploma or GED

No managerial responsibilities

87%

reducing the sample to 155 participants. The final sample contained 25 percent who were both patients and also employees of the clinics. The survey included demographic information and 80 questions regarding job demands, abusive supervision, work-to-family conflict, and burnout. (See Table 1.) All questions were rated on 5-point Likert scale where “1” indicated “strongly disagree” and “5” indicated “strongly agree.” Respondents were also queried about their health behaviors (sleep, exercise, tobacco use, and alcohol use). Measures Medical diagnoses. The top two diagnoses listed for each clinic visit were extracted from each patient’s EHR. They were divided into three categories for each patient: chronic illness diagnoses (a condition that is long-lasting and usually cannot be completely cured), 26

TEXAS FAMILY PHYSICIAN [No. 2] 2018

chronic pain diagnoses (physical pain lasting more than 12 weeks), and “other.” Number of medications. Up to eight current medications were extracted from each patient’s EHR. Medications for each patient were categorized into chronic illness medications (e.g., blood pressure/diabetes medications) and chronic pain medications (e.g., hydrocodone, tramadol, and NSAIDs). The number of chronic illness medications and the number of chronic pain medications were summed respectively for the 12 months of data. Visits to a medical professional. We summed the number of visits each patient had to their health clinic over the 12 months following the survey administration. The range was 1 to 23. Control variables. These included race (non-Caucasian or Caucasian), marital status (unmarried, married, or in a committed relationship), hours worked per week, and health clinic employment (patient only, patient and clinic employee).

Statistical analysis Categorical variables are described with percentages and quantitative variables with mean (SD) or, for data that did not have normal distribution, median. Additionally, a multiple logistic regression model fit to the combined demographic data and responses to job stress questions/health behaviors was used to analyze responses. Race, marital status, work hours, and clinic employment were included as control variables. Because medical diagnoses were specified as dichotomous variables and positioned as outcomes in our hypothesized model, these parameters were estimated using logistic regression with the log odds for these two outcomes representing linear combinations of the predictor variables. Methods for examining mediation based on bootstrap resampling are viewed as most accurate when dichotomous or categorical variables serve as mediating variables, so we followed recommendations by Preacher and colleagues and used a 10,000 bootstrap resampling approach with 95 percent bias-corrected confidence intervals (CIs) to test for the significance of indirect effects reflecting our proposed simple and serial mediation. Indirect effects are significant (p < 0.05) when the 95 percent CIs do not include zero.14-16

Results Demographics are described in Table 2. Job demands (p < 0.05), abusive supervision (p < 0.05), and workfamily conflict (p < 0.01) were all related to burnout. In turn, burnout was positively related to having a chronic illness diagnosis (p < 0.01; OR 1.85) or having a chronic pain diagnosis (p < 0.05; OR 1.75). Thus, a one unit increase in burnout increased the odds of being diagnosed with a chronic illness over the next 12 months by a factor of 1.85. As expected, a chronic illness diagnosis was related to both chronic illness medications (p < 0.01) and visits to a medical professional (p < 0.01). Similarly, a chronic pain diagnosis was related to both chronic pain medications (p < 0.01) and visits to a medical professional (p < 0.01). Having an abusive supervisor was also directly related to the number of visits to a medical professional (p < 0.05). Each of the indirect effects from job demands (estimate = 0.032, 95 percent CIs = 0.003, 0.135), abusive supervision (estimate = 0.054, 95 percent CIs = 0.006, 0.220), and work-family conflict (estimate = 0.064, 95 percent CIs = 0.011, 0.203) to chronic pain medications via burnout and chronic pain diagnosis were significant. None of the direct effects from job demands, abusive supervision, or work-family conflict to chronic pain medications were statistically significant. Finally, each of the indirect effects from job demands (estimate = 0.154, 95 percent CIs = 0.011, .544), abusive supervision (estimate = 0.257, 95 percent CIs = 0.024, 0.924), and work-family conflict (estimate = 0.305, 95 percent CIs = 0.056, 0.888) to visits to a medical professional via burnout and chronic pain diagnosis were significant.

Respondents reporting burnout smoked more (p < 0.01), exercised less (p < 0.038), and had more positive answers to alcohol CAGE questions (p < 0.009) than those without burnout. People with abusive supervisors were less likely to get a flu vaccine (p < 0.05), more likely to get drug testing (p < 0.05), and more likely to be hospitalized (p < 0.01).

Discussion Psychosocial work stressors (job demands, abusive supervision, and work-family conflict) do indeed have an impact on employees’ health care utilization. Work stressors and burnout contributed to diagnoses of both chronic illness and chronic pain. The indirect effect (through burnout and diagnosis) of each of the work stressors predicted each form of health care utilization: chronic pain medications, chronic illness medications, and visits to a medical professional. These results contribute to the advancement of research on stressors in relation to health care utilization. Our findings demonstrate that work-tofamily conflict goes beyond the workplace to impact health care utilization of the employee, emphasizing the need for researchers to more strongly consider the cost of work-family conflict. Additionally, while abusive supervision has been linked with a variety of detrimental work outcomes, previous research has not shown its impact on health care utilization.17 Interestingly, we also found a main effect of abusive supervision on number of visits to a medical professional. This suggests a strong relationship between abusive supervision and diminished health that would benefit from future research. The research using valid health care data is limited and the present research is the first to our knowledge that links specific work stressors with actual health outcome data obtained from EHRs.8 A significant contribution of this research is that we are no longer relying on self-reporting to make the work-to-health connection but now have empirical evidence of a relationship. Thus, while we have known that the psychosocial stressors influence work life (through things like reduced performance and turnover), and family life (through things like family functioning and relationship tension), we now extend that knowledge to show how it also impacts an individual’s health. The study has several limitations. First, a primarily “underserved” population was surveyed. This group of people might be different from the general population with respect to resilience in their response to life stressors such as increasing job demands and dealing with an abusive supervisor. Second, we have just begun to examine the employee utilization of health care but do not have direct costs associated with this use. While certainly costs can be inferred, future research could benefit from directly relating medical costs (i.e., those paid by insurance, by the government, or by the individual) in www.tafp.org

terms of medical professionals and pharmacy expenses. Third, another limitation is while we looked at two key diagnoses in relation to stress, future research could benefit from exploring other health diagnoses. For example, the experience of stress or stressful life events increases the likelihood of digestive disorders.18

Conclusion In conclusion, this research contributes to our understanding of how psychosocial work stressors lead to increased diagnoses related to chronic pain

References 1. United States Department of Health and Human Services (2016). https://www.cms.gov/researchstatistics-data-and-systems/statistics-trendsand-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html. Accessed September 25, 2016. 2. Pizzi, L. T., Carter, C. T., Howell, J. B., Vallow, S. M., Crawford, A. G., & Frank, E. D. (2005). Work loss, healthcare utilization, and costs among US employees with chronic pain. Disease Management & Health Outcomes, 13(3), 201-208. 3. Stewart, W. F., Ricci, J. A., Chee, E., Morganstein, D., & Lipton, R. (2003). Lost productive time and cost due to common pain conditions in the US workforce. Journal of the American Medical Association, 290(18), 2443-2454. 4. Theorell, T., & Karasek, R. A. (1996). Current issues relating to psychosocial job strain and cardiovascular disease research. Journal of Occupational Health Psychology, 1(1), 9-26. 5. Kramer, A., & Chung, W. (2015). Work demands, family demands, and BMI in dual-earners families: A 16-year longitudinal study. Journal of Applied Psychology, 100(5), 1632-1640. 6. Grzywacz, J. G., Casey, P. R., & Jones, F. A. (2007). The effects of workplace flexibility on health behaviors: A cross-sectional and longitudinal analysis. Journal of Occupational and Environmental Medicine, 49(12), 1302-1309. 7. Ganster, D. C., & Rosen, C. C. (2013). Work stress and employee health: A multidisciplinary review. Journal of Management, 39: 1085-1122. 8. Allen, T. D. (2012). The work–family interface. In S. W. J. Kozlowski (Ed.), The Oxford handbook of organizational psychology (pp. 1163-1198). New York, NY: Oxford University Press. 9. Demerouti, E., Bakker, A. B., & Fried, Y. (2012). Work orientations in the job demands-resources model. Journal of Managerial Psychology, 27(6), 557-575. 28

TEXAS FAMILY PHYSICIAN [No. 2] 2018

and chronic disease, and thus to health care utilization. Our research extends research on the links between workplace factors and employee health. Though management research focused on objective health outcomes is limited, our research suggests that job pressure, abusive supervision, and work-family conflict relate positively to burnout, which then lead to chronic pain and disease, and thus to greater use of prescriptions used to treat these conditions and to more frequent visits to a medical professional.

10. Mitchell, M. S., & Ambrose, M. L. (2007). Abusive supervision and workplace deviance and the moderating effects of negative reciprocity beliefs. Journal of Applied Psychology, 92(4), 1159-1168. 11. Matthews, R. A., Kath, L. M., & Barnes-Farrell, J. L. (2010). A short, valid, predictive measure of work– family conflict: Item selection and scale validation. Journal of Occupational Health Psychology, 15(1), 75-90. 12. Shirom, A. (1989). Burnout in work organizations. In: C. L. Cooper, & I. Robertson (Eds.), International review of industrial and organization psychology (pp. 25–48). Chichester, U.K.: Wiley. 13. MacKinnon David P. (2008). Introduction to Statistical Mediation Analysis. Erlbaum; New York. 14. MacKinnon, D. P., & Cox, M. G. (2012). Commentary on “Mediation analysis and categorical variables: The final frontier” by Dawn Iacobucci. Journal of Consumer Psychology, 22(4), 600-602. 15. Preacher, K. J., Rucker, D. D., & Hayes, A. F. (2007). Addressing moderated mediation hypotheses: Theory, methods, and prescriptions. Multivariate Behavioral Research, 42, 185-227. 16. Preacher, K. J, & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 897-891. 17. Tepper, B. J. (2000). Consequences of abusive supervision. Academy of Management Journal, 43(2), 178-190. 18. Armata, P. M., & Baldwin, D. R. (2008). Stress, optimism, resiliency, and cortisol with relation to digestive symptoms or diagnosis. Individual Differences Research, 6(2), 123-138.

“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity to get to know our patients and their families and to take care of them. As members of the Texas Academy of Family Physicians, we don’t just care for our patients in the exam room. We take care of them at the State Capitol, too. “I’m a monthly donor for the TAFP Political Action Committee because if we want policies that are good for our patients and our practices, we have to elect politicians who understand our issues. Support TAFPPAC and make your voice heard.” Justin Bartos, MD 2016 TAFPPAC Award recipient

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PERSPECTIVE

Prescribing for opioid addiction is my responsibility By Alan Schwartzstein, MD i consider myself to be a caring, comprehensive family physician, but when the FDA approved buprenorphine (Subutex) and buprenorphine with naloxone (Suboxone) for opioid addiction in 2002, I was skeptical. Federal law requires physicians to pass an eight-hour course and apply for a waiver to prescribe the drugs, and this would put me in the position of attracting more patients who had addictions into my office. Considering the frustrations that we all face at times with these patients, I figured someone else could do that, not me. Times have changed, and not for the better. The opioid epidemic is getting worse. Two to three people die of overdoses every day in my state, and one dies every 20 to 30 minutes nationally. The U.S. overdose death rate in 2008 was nearly four times what it was in 1999. Sales of prescription painkillers in 2010 were four times higher than in 1999. Finally, and most disturbing to me as a prescriber, prescription opiates — not illegal drugs like heroin or “street” morphine, but our legal scripts! — are the leading cause of morbidity and mortality in those who are prescribed opioids and/or addicted to opiates. Opioid use — both prescription and the illegal variety — has skyrocketed, but the number of physicians available to help those affected has not. According to HHS, less than half of the 2.2 million Americans who need treatment for opioid addiction are getting it. The Pew Charitable Trusts has noted, for example, that almost 500 patients in Vermont are on waiting lists to receive medication for opioid dependence. For the majority, the wait will last nearly a year. The issue of supply and demand for approved prescribers isn’t limited to that state, and the long wait for help proves too long for many. My patients need help, so it has to be me. I have to take responsibility. In the past month, three patients came to me wanting more opioid medications or refills that I did not feel were appropriate. All three essentially said that if I didn’t prescribe the medications, they could get drugs — more easily and cheaply — on the street. Those drugs, of course, are unregulated and dangerous, and some are illegal. I asked myself why I didn’t have anything else to offer them. The tipping point for me came when Aleksandra Zgierska, MD, PhD, a family physician from the University of Wisconsin School of Medicine and Public Health, made a presentation at a Wisconsin AFP Board meeting. It was a practice changer for me. I was reminded that addiction is a chronic brain disease, not a weakness of character or a social, moral, or criminal justice problem. Medication for opioid addiction is not a new addiction, but treatment. Buprenorphine can be prescribed in the office, as

opposed to methadone treatment, which may require my patients to drive 50 to 100 miles daily. Most importantly, it works! Like diabetes and hypertension, treatment of opioid addiction involves counseling, medications, regular lab tests, routine visits and thoughtful management. And, according to Zgierska, treating opioid addiction with buprenorphine can work as well as common treatments for diabetes and hypertension. She noted that after six to 12 months of treatment with buprenorphine, 50 percent to 80 percent of patients no longer use opioids. By comparison, after the same length of time in treatment, 40 percent to 70 percent of patients have type 1 diabetes under control, and less than half are adhering to their medication regime. Twenty percent to 50 percent of patients with hypertension achieve good control of their condition during the same period, and less than 30 percent adhere to medical therapy. Medication-assisted treatment allows patients to lead normal, productive lives. Every dollar spent on treating opioid addiction saves society as much as $7 in drug-related crime and criminal justice costs and $5 in health care costs. Now I felt I could offer my patients something other than referral to a long waiting list. So on a recent Saturday, I took the American Society of Addiction Medicine buprenorphine waiver course and applied for a waiver. The cost was $200, which was a bargain considering I can report eight hours of CME. I learned that prescribing and monitoring MAT is easier than I thought, and I can do so in my office with the type of adjustments that we make to treat hypertension, diabetes and other chronic diseases. Barriers still remain, including costs, patient motivation, a dearth of treatment programs and, most importantly for AAFP members, lack of access to MAT. You and I can address this lack of access to care. Family physicians account for 20 percent of U.S. office visits, but we comprise less than 20 percent of physicians who are approved to prescribe buprenorphine. The call to action in the AAFP’s policy on chronic pain management and opioid misuse urges family physicians to “consider obtaining a Drug Addiction Treatment Act of 2000 waiver to deliver office-based opioid treatment.” I hope you will consider getting the waiver, like I did, and implementing MAT in your practice.

I was reminded that addiction is a chronic brain disease, not a weakness of character or a social, moral, or criminal justice problem.

TEXAS FAMILY PHYSICIAN [No. 2] 2018

Alan Schwartzstein, MD, is speaker of the AAFP Congress of Delegates. This AAFP Leader Voice post was originally published in October, 2016. Source: AAFP Leader Voice, October 16, 2016. © 2016, American Academy of Family Physicians.

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