Pain Management ECHO: Health Alternatives for Pain Management – 1/3/18

Pain Management ECHO: Health Alternatives for Pain Management – 1/3/18


– Well hello everybody. Welcome 2018, we’re started here. First, a bunch of thank yous to everybody. Troy, and Chris Marchand,
and Jordan Friend, and of course Dr. Evan Class for making the ECHO program available and actually do a lot of work behind the scenes that many people don’t get to see. But there’s a whole bunch
of work that goes on. Also, University of
Nevada School of Medicine and with Dr. Lewandowski. Today Dr. Patterson is
not available today, but he will be back for our next one. That’s our regular panel team. Dr. Lewandowski has been a
psychologist for over 30 years in his clinical experience
in pain management and just a plethora of wisdom and all kinds of wonderful things. I specialize in substance
use disorders and dependency. And I have a license in Nevada
as well as in Minnesota. And so I want to thank
you all for being here. We’re going to go over a couple of things. One of the great things
about the ECHO program is the flexibility and recognizing now that we have the AB474
regulations that are coming up. We thought it would be prudent
to touch on those first and then go into the alternatives for pain relief treatment and management. So we always open up in the beginning, get some introductions as well as find out if there’s anything that
you need help staffing with or any complicated cases or anything that is on your mind that
you’d like to utilize the whole group for because we have all of the wisdom out in the
community who are piped in and we want to be able
to tap into everybody’s experiences to provide
optimal healthcare throughout. So let’s start off, we have well there’s Dr. Cole up in the corner there. – Good morning Barry. – [Dr. Cole] Hey good morning everybody, happy new year, I’m sitting with my grandson if you hear him screaming. (laughter) – Wonderful. – Always good to have you Dr. Cole. – [Dr. Cole] Early how
to be a pain specialist. – Say again. – [Dr. Cole] I have to teach him early how to be a pain specialist. (laughter) We all become old people no
one’s going to be prescribing. – That’s right. – Okay, and who else? Linda Garrett. – Hi everybody, I’m Linda Garrett, I’m the Icon Risk Manager. One of my concerns with
AB474 is patient abandonment. I’ve been, for the last
year, trying to convince our doctors that you can’t
just quit patients mid-stream. And I’m interested in
knowing what kind of support we can give our doctors, primary
care providers especially, to continue to treat their patients and do it in a medically appropriate way. So… – Very, very good point. Very good point. I also see that as an emerging concern. You know, what’s going to
happen to a lot of folks that have legitimate persistent pain that are just kind of let go. Yeah. – I think physicians are
angry that the legislature is telling them how to practice medicine, and that anger is being kind of dumped off onto their patients. – Sure, you bet. – Yeah. – Penny Koss. – Hi, nurse practitioner
out in Lovelock, Nevada. – Hello. – Good morning. – Welcome. – And Alan? – Hi, I’m Alan Fisk out in Elko, and I’m just here for
the technical support. – [Dr. Lewandowski] Wonderful. Good to see you. – And who do we have from
the Reno Sparks Trail Flight joining us today? Just a second, let me take you off mute. – Oh, that is Dr. Nobel. Yay, Dr. Nobel. He is our medical director
over at the Reno Sparks Indian Colony. Thank you so much. – We’ve got audio issues. I can’t get you guys
unmuted for some reason. – Uh oh. – And Dr. Postman? – [Dr. Postman] Good morning. When you get to it, I have a couple questions from the presentation two
weeks ago regarding sleep. – Okay, absolutely. – Thank you. – [Troy] And Tony, I’m not
sure if we have audio from you this morning. Make sure that you click
the join audio in the lower left corner of the Zoom screen. – [Woman] Hi, I’m actually on phone. Pardon the screen. And I am the CEO at South Lion and have enjoyed Linda’s
counsel for many years so I’m thankful for that. While I echo Linda, and Linda’s concerns, I’m also having, one of
the requirements of AB474 is after 90 days, the addiction assessment, and while I can find some, a lot that point
to alcohol-specific, I am having a really hard time finding a reviewed or
an accepted, you know, peer-reviewed assessment
for the opioid addiction, and if there’s anyone
out there that might have a sample or a recommendation, I would really appreciate it. – Are you looking for an evaluation? – [Woman] It’s required, in AB474, after a 90-day prescription, then it’s requiring that the provider perform, and it looks like
an addiction assessment. So I, and as I said, while
I can find one specifically, you know, with alcohol, I’m having a really hard time finding one that I feel meets the
requirements that is more the opioid-related or the drug-related. – There are certainly a couple, and we can certainly talk about that. The opioid risk tool from
Dr. Lynn Webster is one that I know is being used
to meet that requirement. The SOR is another, so we’ll
certainly talk about that and maybe where you
can get some references and some of the companies
that are providing those for physicians for use kind of online. So we have to talk about that. – [Woman] And this is
unique from the risk tool that you use on the initial prescription? It’s the one after 90 days, so absolutely, I appreciate all the help I can get. Thank you so much. – [Dr. Lewandowski] We’ll do our best. – And Tyson, do you want
to introduce yourself? – [Tyson] Yeah, I’m Tyson McBride, out in Lovelock, just
a physician assistant and enjoy watching things. And so far I have no questions yet. – Hang in there, good to have you. – Dr. Van Gelder? – Morning, I see you. Late start. I’m Dr. Van Gelder out
in Lovelock, Nevada, and as always, I appreciate
your guy’s assistance. Thank you. – [Troy] And William B. Reilly, it looks like we have Dr.
Christianson with us this morning, but your video’s frozen. It seems like the audio
is working fine, though. Dr. Christianson, are you there? Maybe not. Okay. Becky? – Hi, Becky Bailey from Nevada
Rural Hospital Partners. Can I ask you to repeat the name of that assessment tool you
mentioned just a minute ago? Yeah, the opioid risk tool. It’s the acronym ORT, and it’s Dr. Lynn Webster. He’s right our next-door
neighbor here in Utah. He developed that test. It’s peer-reviewed, it’s, it means, I think,
what the intent was of the law, coming up with
the scientifically derived assessment device for opioid issues. And the same with the SOAP, which I believe is the Subjective Opioid Assessment… I can’t remember the rest of the acronym. But that’s another
instrument that I think meets the state’s requirements for
peer-reviewed, scientific. – There’s actually a link to that one from the state’s website, and are going to put a lot of the resources on our own website, and so, Tony, for your knowledge, it takes a couple of clicks to get to this one, but I’ll download the
tool and put it right on our website and send
it out to everyone. – Thank you, that’s wonderful. – We’re just doing introductions. Elle Broton? Can you introduce yourself, please? – [Elle] Yeah, can you hear me? – Absolutely. – Alright, yeah, clinical
psychologist here at Community Health Aligns, doing integrated behavioral health. – Welcome. – Welcome. – [Elle] Thank you. – DAJ. – [Troy] Uh, Chris? – [Chris] Chris Marchand,
Director here at Echo Nevada. -[Troy] And Pete Rogers, I
don’t believe we have audio, but you are another social worker at the Community Health Alliance. – Good, good, good. – [Troy] We have someone signed on, her screen name is just a period. I don’t know if we have
audio for you either. If you could send your name in via chat, that would be great. Sieguro? Are you there? Laurie Sportsoff. Maybe no audio for Laurie this morning. And Ann Drell? – [Andrea] Yes, this is Lisa Andrea. I’m the Humboldt General Hospital
Quality Services Director. – [Troy] Great, thanks so much. Glad to have you joining us. – Alright, let’s get started. Again, thank you all. Okay, so, while we’re
going through the slides we’re going to be talking
about patient abandonment, we’re going to touch on some sleep and post-90 day evaluation. With that in mind, feel
free to jump in anytime and, especially if you
have any insights into those three topics, or you have some burning desire or something that comes up, please feel free to jump in, make this as interactive as possible. So, we’re going to start with the AB474 compliance checklist. Okay, this looks kind of complicated. This is from the Nevada
State Medical Association. This chart, this flow chart, is available. We’ll send out the link here. And what it does is it goes
through, really nicely, a quick screen tool to give you an idea of the flow of everything
that needs to happen for the initial prescribing for controlled substances. Troy, can you back it
up just a little bit? There we go. Okay, see the blue? Start at the upper left-hand
corner right there, that’s where we’re starting. Now, just follow that around. Look at the little hand
go all the way over, down, across, up, and there’s your gold bar. So that’s the game. If there’s two areas here, that say it doesn’t apply, and you can prescribe
according to standard of care. So, primarily, you’re looking
at these controlled substances going through these, the blue
little steps, if you will. So, are you prescribing
a controlled substance? Number one, check the PMP. Evaluate risk factors. Is the prescription for pain? This is the other exists thing. If it’s not for pain, you go straight to the
legally valid prescription. If it is for pain, then we go down, establish a bonafide partner, or provider-patient relationship. Establish the primary
diagnosis and treatment plan. Consider alternatives
to controlled substances and document in medical record. Evaluate HERR, or medical history, physical examination, obtain medical records, risk of abuse, document in the medical record, good faith effort to obtain records. Obtain informed consent, then identify
patient-specific limitations. For acute pain, that’s 14-day maximum. For opiate naive, no more than 90 morphine milligram equivalents, and for 30 days or more,
complete a prescription medication agreement, which will be, we’ll be
showing you all of these agreements and contracts
that are already available on the state website, too. Then you’re ready to prescribe, then you go with the complete
a legally valid prescription where you need the
patient’s date of birth, the ICD-10 diagnosis, minimum number of days
for patient consumption, and prescriber’s legal
name and DEA number. Now, before we went into this flow chart, I was talking to Dr. Lewandowski and he has a really
nice way of visualizing how to categorize two
different types of patients that the, or the ones that may be the narcotic or the controlled substance, and then the other one. – Yeah, we were just
chatting before we started, and I imagine this as having two buckets. It’s all under the heading
of controlled substances. In one bucket would be for
those who controlled substances who don’t have anything to do with pain, and you can see some of the
steps that are required there, there are fewer steps in this model. And then those controlled
substances that are used for pain management, which
requires all the rest. The more in-depth process. So, the thing that I think
is important to realize is that it’s for all
controlled substances. This new AD474 addresses all of those. I think it’s schedules
two, three, and four. So that was helpful for me
to kind of conceptualize how they fall into two
different major categories. – Sounds good. Any questions with the flowchart? Okay. If they come up, just let us know. Okay, so then the next few
slides we’re going to look at before writing the initial prescription. We’re looking at a bonafide
relationship with the patient. Have I established the primary diagnosis, and what is the diagnosis? How do you set up the diagnosis? Is anybody setting up diagnosis now? Okay. Have I conducted a check with
the patient’s prescription history with the PMP? What’s the history, have
I documented this review of the PMP and patient chart? Have I discussed the non-opioid
treatment with the patient? Why was the non-opioid
treatment not prescribed? Is there a reason to believe
the patient is not using the controlled substances prescribed? Or is diverting the controlled substance for use by another person? Is the previously prescribed
controlled substance had the expected effect on
the symptoms of the patient? Is there a reason to
believe that the patient is using other drugs,
including without limitation? Alcohol, controlled substances
listed in schedule one, or prescription drugs that
may interact negatively with the controlled substance
prescribed by the practitioner or have not been prescribed by me? You getting the picture here? It’s a lot of work before
we’re prescribing this stuff. How are you going to do
that in seven minutes? This is where the team approach comes in. This is where you need,
when you’re looking at someone new is before
they’re being prescribed, you want to be able to
go through all of this, put checks in the box, and
make sure that this is the, this is the appropriate medication, appropriate timeline. And then we’re also looking at, what is the goal, really, and what’s the exit strategy? So if we keep those two things in mind, and have another team member
who’s able to go through all of this, all of these criteria before setting up the person with an opioid, everybody will be on the
same page and you can go and see more patients. Does all that make sense? – I have a question. – [Troy] Yes, please. – Any advice on how to deal with patients that attempts to refill early? – Yes, that will come in
the medication agreement, and the answer is no. If your dog eats your prescription, sorry. If you’re shopping around or if you have multiple prescriptions
that doesn’t look like it’s gonna work again. And so, that’s part of the
patient medication agreement, that everybody stays on the same page. And that’s the whole idea. It’s to stop diversion,
and it’s to stop overusing, it’s to stop putting people
at risk for these narcotics. – [Troy] A question here from Dr. Cole. Marijuana is a schedule one drug. Will anyone prescribe any
other controlled substance if the patient is
lawfully using marijuana? – Okay, let’s go back. Okay, in prescription
medication agreement, must include goals of treatment, there’s our goal, consent to testing, to monitor use. So, drug screens. Requirements that controlled
substances only taken as prescribed, prohibition or have prohibited sharing. Requirement that the
patient informs the doctor of other controlled
substance prescription taken, and there it is. Use of alcohol and/or cannabinoids. Here’s the thing with marijuana and THC. It’s a very huge umbrella. The stuff that we’re
smoking 20 or 30 years ago is being were to have a
garbage bag of Mexican ragweed to catch a headache is
no longer available. The stuff that’s out there
right now is a lot stronger. And so we’re going from 12, 15 percent THC up to 95 percent THC and dabs. And so you have to find
out what is in the person’s system, and then find out
also, what the strength of that THC is. And so, yeah, we’re going to have to know. When we’re looking that up, just look at all of this stuff as substances. Take everything else out of the equation. But I have a lady who did not have a problem at all getting off of benzodiazepines. It’s like, “Whoa, how did you do that?” She used it because she couldn’t sleep and she was feeling a little anxious at night. She was only drinking four glasses of wine before she went to bed. So, to the receptor system, you think of benzodiazepines
as powdered alcohol. So she was just substituting
one for the other. And the important thing is, you figure out what is going on in the person’s system, and that’s where another team approach comes in, because once I’ve worked with
someone and we get the stuff out of their system, then we start playing whack-a-mole, because we have behaviors that are going to start coming up, and the addiction
is going to change form from one area to another,
so it’s just keeping the puzzle going. Looking for healthy,
productive alternatives. And that’s where the
team approach comes in. – I’m curious, if I could. How many, that are here today, that do, that don’t have a
problem prescribing an opioid if marijuana is also being acknowledged? And if you could speak to
that, and the rationale. Are there any providers who do both? Yeah. – So, I have had a couple
of patients who are not currently my patients now. And they were on marijuana
just to kind of sleep. And in the past I have
addressed that with them, and I know many providers
will not do both. It’s hard to really know if
this patient is a reliable patient, but just discussing the risks of, this is another substance
that acts on your brain, and it can impair you
and the risks of driving and operating things are
increased when using both of these together. I honestly am probably
going to be changing my decision about allowing both, based on all the current new information on our new marijuana that’s
out and the prevalence of it. But, I don’t know. We’ll have to see. – The difficult thing with marijuana, unless it’s Marinol. Nobody talks about Marinol anymore. It’s been out for 20 years, and it’s THC. That’s regulated by the FDA, its consistency, potency, purity, dosing, directions, it has all that stuff. It has studies. Or if it’s CBD, are you
talking about Epiodolex? That’s been out. It’s GW pharmaceuticals. These are all regulated by the FDA. Who regulates the marijuana
coming out of the dispensaries? The department of taxation. – [Woman] Right. – Kind of puts that
into perspective there. What’s the dosing, what’s
the potency purity? How’s it being fertilized? What are they smoking? What kind? What’s the THC level? How can you keep it consistent? Does your insurance company
reimburse you for it? What does the recheck look like if you go in for a backache? Does the blood test hurt? Do a range of motion tests? Or do they just sell you
the next little baggy that’s up on the thing? What’s the difference
between medical marijuana and recreational marijuana? It’s the label. Okay, so, there is nothing
really, that I know of, that I’ve come across of, that
show marijuana is a medicine. Unless you’re talking about Marinol. – So that will end up being an
individual practice decision, I assume, and it sounds
like you’re maybe changing your perspective? – Well, it was a very, it
was a very limited population of patients that I would
even really consider that. But I’m rethinking it. Could you speak to the CBD oils? Because that’s a huge
thing I’m seeing right now. And, what your feelings are on it. – Mind there’s 480 compounds
in a marijuana plant. THC is actually the
plant’s natural pesticide. A bird or an animal
will eat it, feel funny, and will avoid it,
saying “This is not good. This gives me an altered
state of consciousness.” Human beings can’t get enough of it. (laughing) CBD? I don’t know. There’s Epidialex. And that has been, that’s
a CBD-based pharmaceutical that’s regulated by the FDA. And there’s things like
Charlotte’s Web and different CBDs available. I think they need to be studied more because I have people
that I work with that marijuana actually
promotes seizures in them. And again, what are you taking? How are you taking it? Are you smoking it? That’s a completely different system than if you’re eating it. If you’re eating it, it’s
gotta be metabolized. If you’re taking it in meal
form, it’s gotta be metabolized. Once it’s being metabolized, you’re along for the ride. If you’re smoking and it gets, you get a little bit too high,
you can always put that out, kind of control it. But once those receptors are impacted, it depends on how you’re taking it, what you’re taking. It’s between the moon and whale dropping, what the truth is. And that’s the problem. It’s a moving target. – [Barry] Hey, this is Barry again. I put that question up just
to focus on the reality that we now live in Nevada, with California next to us
where you could go in now as an adult and purchase
any amount of marijuana to the statutory limits. But I’ve crossed this bridge
before, and I practiced at Kaiser in Honolulu, and we
had a medical marijuana law that let people walk around
with four ounces of marijuana in their possession, which
is a big bag of marijuana. If you think about what
four ounces looks like, the reality is, we prescribe
under federal authority, marijuana is a C-1. I don’t see how you can
ever write a C-2, 3, or 4 when they’ve already broken federal law and your ability to prescribe
controlled substances is granted only by the federal government. Yeah, in Nevada we get the extra card, but you can’t even get
that card if you don’t already have a DEA certificate. So to me the absolute line
in the sand is the DEA, which says, you know,
you can’t do C-1 drugs in the United States. Who cares what the state of Nevada thinks. Now on the flip of that,
remember a couple of years ago it came out in JAMA
that in states that have medical marijuana laws,
that the opioid overdose rate was actually lower. So people stopped,
presumably, dropping benzos with opioids. Yeah, they did smoke
marijuana with their opioids, but it was a less fatal
outcome because you don’t get respiratory depression from marijuana. So I’m going back now to the
way I’ve had to face this. I tell patients there’s two doors. Left, right. The left door, I prescribe opioids. The right door, you do whatever
you want with marijuana. Both may actually be clinically effective, but under my prescribing authority, you can’t do both at once. You choose. And I mean, to me, that is the ultimate informed consent. You choose. Here’s the information, it’s
your decision, it’s your risk. Anybody else going to take that approach? – We’re starting to see more and more issues with marijuana use. Driving under the influence. Things will start popping up. I’d always take a conservative approach. Wait for studies to come out. Wait for things to kind of bubble up. It looks like the pendulum
is going to be swinging. Who remembers candy cigarettes? Are cigarettes good for us? Remember when smoking was used for asthma? Who remembers THC-infused gummy bears? What are we doing? – An interesting point
that Dr. Cole brings up. It may come down to an
individual’s decision. Both Paul and I are
blessed in some respects. We don’t have the power
of writing the script. So it’s not an issue
we’re going to be facing, but it will be an issue
that you have to face, and looking at the federal
laws or state laws, and the implication that
it has for your license and your practice is huge. So I don’t, you know, I don’t, I feel for the position you’re in. Add to that what was said earlier, that introductions with the comment about what are we going to do with the number of these patients that will be, in effect,
abandoned from their opioids, and their doctors said, “You’ve got to see a pain specialist.” But the most official pain
specialist is so overbooked that it’s three months to get
in, what’s going to happen? I think it’s going to be
interesting to see where people will turn. And they most likely
will go with marijuana as an alternative, as a guess. But I don’t know. Are there any other thoughts out there? – Yeah, they go to the emergency rooms. That’s where they always go. In an emergency they go
to the emergency rooms, and I suspect our ER
colleagues are not going to be happy very quickly. – Yeah, yeah. Interestingly, yeah. And if I read the law AB474 correctly, emergency room docs and
hospitals in urgent care do not… The AB474 is not applicable, so they don’t have to do an opioid risk at that point, if I’m reading that correctly. Is that your understanding out there also? So they’re exempt, from what I read. But that’s where the
funnel is going to go. It’ll be in the ER rooms. – It will. And keep in mind, too. Physicians can’t prescribe marijuana. Pharmacies don’t carry marijuana. Insurance companies don’t
cover the financial part of marijuana. So, if you’re sticking to
prescriptions as a physician, you can recommend, but you can’t write a prescription for it. Okay, so we have, before I can write an initial prescription, here are all the checks. Before I can write an initial prescription I must identify has the patient increased his or her dose of the controlled substance without authorization from the practitioner? Has the patient been
reluctant to stop using controlled substances or
has requested or demanded a controlled substance
that is likely to be abused or cause dependency or addiction? Is the patient reluctant
to cooperate with any examination, analysis, or test recommended by the practitioner? Does the patient have a
history of substance abuse? Is there any major change in
the health of the patient, including, without limitations, pregnancy, and/or diagnosis concerning
the mental health of the patient that would affect the medical appropriateness of prescribing
the controlled substance for the patient? Is there any other evidence
that the patient is chronically using opioids,
misusing, abusing, illegally using or addicted
to any of the drugs or failing to comply with the instructions of the practitioner concerning the use of the controlled substance? Is there any other factor that
the practitioner determines is necessary to make an
informed professional judgment concerning the medial
appropriateness of the prescription? So, again, another
reason to have somebody, before they see the
physician, actually go through all of these criteria. Another thing is, You know, when I work with somebody, in substance use or substance dependence, whether it’s physiological
or psychological or addiction, the idea is
they’re not a bad person. The idea is, to get them off whatever the substance is and not label it because it’s all… If we introduce anything
to our body or our brain consistently, or body and brain will become accustomed to it. And so, the idea is to have
them be less of a hostage to whatever the substance is. And so, when we’re looking at this stuff, when we’re looking at
marijuana or we’re looking at opioids, we’re looking
at benzodiazepines, we’re looking at alcohol, it’s all kind of the same stuff. A lot of the treatment is the same. It’s getting to know where
that person wants to go and how to move them forward and progress in the stages of change. And they get to see that through payoffs. And here’s the problem. If you’re taking somebody off of opioids that’s been on them for 20 years, and all of a sudden we’re changing the thought process and exposing those nerves
that have been covered up for so long, that the body
has become used to it, that the pain signals haven’t stopped. They’ve actually been amplified. Now we rip that off, we
don’t give them the security blanket or the go-to by
taking away their substances. That requires the team effort. That requires getting into the brain and helping them walk out
of the force that it took them 20 years to walk into. And that’s a complete
change of thought process, lifestyle and, a lot
of times, environment. So, when we’re doing
this wraparound service, we’re looking at, how can
somebody screen all of this stuff in a time-sensitive way
that will validate your time and take care of that patient. Here’s another thing for
the initial prescription. What type of prescription
do I propose writing? What’s the duration? Is the prescription for
no more than 14 days? Have I considered the 90
morphine milligram equivalent limit for opiate-naive patients? Or is there just a blanket
statement out there that says that you’re
going in for surgery, this is what you’re
going to be exposed to. I have completed the
Patient Risk Assessment, the patient has completed
the Informed Consent. Here’s the Patient Risk Assessment. – Can I go back one? – Yep. – If you look at the fifth point there, I’ve completed an assessment
of the mental health and risk of abuse. The one work that I’d
like to emphasize in that that I think is really
critical is the word “and”. If you look at mental
health and risk of abuse, that would suggest that
that is potentially a two-step process. So,
just measuring opiate risk measures the second
part of that statement. It’s not necessarily measuring
mental health, so it may be that you need to do two assessments to fully meet the criteria of
completing this assessment. And I just raised that
point, because I consulted an attorney, and attorneys love words and they dissect everything, and that word jumped out. The word “and”, meaning in addition to. So those could be perceived
as two separate things. I’m not sure the writers
of the law intended that, but when it comes down to legal matters, that word “and” can
make a huge difference. So, my encouragement
to all of us out there would be to take a look at finding, and at least covering both
the mental health as a separate issue from dependency,
addiction and abuse. And so, I think that’s it. And if I could make one other comment. I believe AB474 may turn out
to be the mental health bill in Nevada, because, let me propose this. If you’re being asked
to identify the risk, and you’re identifying risk, and in this case identifying
some mental health issues, potential opiate addiction issues, and you don’t do anything about it, you’re going to be liable. So, you better have, I
encourage you all to consider honing up or partnering as a team, that Paula has said a number of times, with some mental health people, whether it’s addiction specialists, pain
management psychologists, licensed clinical social workers, to be able to then make
a referral for those needs, because you can identify them by doing these, by taking these steps. And now I think, again,
for my attorney friends, it’s increasing your potential liability. So, I would just make that
comment on this particular slide. – That’s a great comment,
and that’s another point, I’m blessed to be working
with really solid company. Good psychiatrists, and we
have clinical psychologists and mental, family practitioners. We just have a really strong team, and so usually, if somebody is referred to me, we can do it a lot of times in-house, and when they’re referred to me, I can recognize that
this is a package deal. If the person is dependent on opioids, and we were going to get the
person off of the opioids, then we have anxiety,
depression, remorse, grief. All kinds of stuff that comes up, and it’s almost, you can
take a lot of the stuff on a timeline and say, “Now
that the person is getting over this, or, hey, person,
this is what you have to expect.” And this timeline, in this
area, you’re going to get some insomnia. I’m going to work through that with you. And you’re going to feel like anxious, and you’re going to feel nervous, and you know what? You’re going to be snapping at people. And you know what? That’s a good sign. That’s healthy. I’m going to work with you, letting you recognize what coping skills you can use while you’re going through that symptom, because it’s your body’s just getting adjusting, getting ready to get on that healthy path again without the substance. – So you work in a facility
that has interdisciplinary all under one roof. – I do. – And hospitals, of course,
do, too, if you have behavioral health departments. But I think the concern is for
the primary care physician, the lone rangers that are out there. My advice would be to
just consider hooking up with some mental health
agency or mental health group that could, that you
could make referrals to when you identify this risk. – You do, and also, interview. Not everybody is created the same, and so you want to make sure they have the same philosophy that you do, that you’re on the same thought process. That you have the timeline set up. That you know what they’re going to offer, which theories they work on. What are their methods? What are their, just, who are they? Because you get somebody that’s a licensed alcohol and drug
counselor, it doesn’t mean that they all have the
same thought processes or theories or philosophies. – [Barry] Hey, this is Barry again. I just want to agitate one more time. Read the product insert, you know, the PI, for Oxycontin. And know that it says, “Risks
are increased in patients with a personal or family
history of substance abuse, including drug or alcohol abuse, or mental illness, e.g. depression.” And the reason I bring this up, this coming Sunday down in Vegas, Don Havens is going to
be putting on a seminar with Joe Hardy, and the bottom line is, one of their hand-outs is the
Beck Depression Inventory. In other words, we now need to screen everybody for the possibility of major depression, since it’s right in the PI for Oxycontin. You better clear them of depression. You better also clear
them for everything else, and remember, if you do
chronic pain management, 50 percent of all of your
patients will meet the criteria for what used to be called an access two personality disorder. And the only good news is, 15 percent will be borderlines. The rest won’t. Think about what that means. – Yeah, good call. Yeah. – Here’s your informed consent form. – [Barry] Yeah, Don
Haven sent two different informed consent forms to me. One is very different from the other, because it’s more about,
like, making sure women don’t conceive while on opioids, which is sort of interesting,
because if you take opioids appropriately, men will probably
have a lower sperm count, and women become anovulatory anyway. But, you know, we now have
to get into this whole idea of neonatal withdrawals
syndrome, and then you send another one of the
informed consents that has, sort of, a different
legalistic perspective. If you need to, you might
want to reach out to Don to get these handouts,
because there is no room left for either Sunday or next
Wednesday’s conferences in Vegas. Touro University sold out immediately. – A couple of other things. If you’re looking at the
second-to-last point, if the controlled substance is an opioid, I’ve discussed with my
practitioner the availability of an opioid antagonist
without a prescription. And so, we look at,
why would we need that? It’s not to demonize opioids. But in some of these… Everybody takes opioids or is not going to be addicted to it. But a lot of people,
especially elderly people, don’t understand what’s
happening with the opioids. So if they have a flare-up, and they take their Oxycontin, and they have a little bit of wine, and then they take another one, many of the overdoses happen accidentally. And so, the opioid antagonist is available. It’s over at HOSS. You can get a couple of
syringes for 25 dollars, and that’s just to blast
off those opioids receptors to get them the help that they need. It’s not to say that
everybody who’s going to have an opioid is going to be taking this and using it or diverting it, but enough people have been doing that, that it’s caused for this kind of action. If the patient returns after 30 days, then we have the prescription
medication agreement. There’s the prescription
medication agreement. Patient agrees to test to monitor drug use when deemed medically
necessary by the practitioner. Okay, so if somebody comes in, like clockwork, every month they’re getting their 60 pills, their opioids, and they’ve been coming
in for a year and a half. And they’ve never asked for more, they’ve never asked to be titrated down, and you decide to do
a drug screen on them, and they don’t have any
opioids in their system. Something to think about. Patient agrees to take
the controlled substance only as prescribed, the patient agrees that sharing medication with the other person is prohibited. This is something that
we get into with people that say, “Well, the doctor prescribed it, it’s gotta be good. So I ran out of mine so I
went over to my neighbor. We has the same kind, so we just share.” The patient agrees to
inform the practitioner of any other controlled
substances prescribed to or taken by the patient. Just, you need to know what’s
in that person’s system. Whether the person drinks
alcohol, or uses marijuana, or other cannabinoid compounds while using the controlled substance. And that’s not to
demonize marijuana either. The whole idea is that you have to know what substances, regardless
of the thought process behind it, what’s substances
are in that person’s system, and how are those substances
interacting with each other? What is going on? How are they being metabolized? How is one impacting
the other’s metabolism? How much are they taking? How are they taking it? – If I could add, I’d love to reinforce
the idea that this is and agreement, not a contract, so it’s not a legal issue. But, with an agreement, this
facilitates the conversation between the doctor and the patient, which is what really needs to happen. That the patient needs
to realize that they’re, that this is their pain management, and they’re playing a major role in it. It’s not all up to the doctors. This is a mutual agreement,
and it facilitates that conversation. I think in that respect
this is a very helpful tool. – That is a really good tool. Also, screening tools where
you can see and work with the patient to see their progress. So that they’re part of the progress. They’re excited for the
results, seeing the measurements go down, and see their
health getting better. Okay, so that’s the prescription
medication agreement. You can read the rest of it. If the patient returns after 90 days, more criteria. Risk of abuse assessment. If the patient returns after 365 days. This is supposed to… 365 and not prescribing
more than 365-days worth of medications, which
sounds kind of obvious in the beginning, but, if the person has used
365 days of medication in eight months, then, probably you have an issue. Oh, I’m sorry. Check the PMP. I have completed a check
of the PMP every 90 days. And now we’re getting into
drugs, alcohol, and health. So, are there any questions? Like, Linda, when we were talking about patient abandonment, does anybody have any solutions
for the patient abandonment? – Could I also ask one other question? You mentioned a few minutes
ago that you believe that the emergency room doctors are exempt from 474. I know there was discussion
about hospice programs and emergency departments
not having to follow 474, and I’m not aware of that. I just rechecked 474, and
I can’t find any exception for emergency departments. – Well, let me do a check with
some of my documents here. But, like I said, I think that
is an important distinction. Certainly. – We will definitely look that up. You know, with the patient abandonment, that’s where… One of the things that
kind of jumps out at me is the team approach. And so, not letting the
physician just be there, out there alone, and that’s one of the
reasons for the ECHO program, so that we can all discuss,
what are the best strategies for providing optimal care
with the limited amount of time that you have, and all of these new regulations
that are coming down. And these, like Dr. Dumero, was saying, this isn’t a request. These are requirements. And so, we’re looking at that, if you have a team approach, and, like me, for example, I’m talking to, we have
released that information, so I can talk to the psychiatrist and let the psychiatrist know, while the patient also knows, and we’re all working together, and this is what we’re working on, and then, if relationship issues come up, and I go to my marriage
and family therapist, or my, or my professional counselor. We also have medical and dental. We can bring the whole team together. And so, I can see that
person for an hour at a time. For a week. Every week. Sometimes multiple times, if I need to, for a temporary amount of time. I’m not going to grow old with them. But then, I’m not going to
spend 20 years going over the same thing, because
that’s showing that the cycle, the medication cycle, that’s a medication management
kind of cycle model. – If I could, I have a
question and answer kind of. Frequently asked questions for AB474. I’d be happy to share this with you. It says, “Are hospital
and stand-alone emergency departments required to
comply with the requirements of AB474?” Let me read you what it says here. It says, “AB 474 applies
to all practice settings where controlled substances are prescribed or dispensed for pain. The requirements of AB474
do not apply to medications ordered for administration
to the patient on-site, including in an emergency
department or clinic or in a hospital. The citation is AD474 sections 51 to 64.” So, I’d be happy to share
it, the document I have. It’s AD474 Frequently Asked Questions. – However, if, if you’re
going to prescribe from the ER, or in all our ERs we actually dispense for weekends, because we don’t have a pharmacy here. We’re dispensing any for outpatient use or writing a prescription
for outpatient use, we’re required to still
have them sign a consent. And we had actually started
that in our ER this week. I’ve gone to the ER. But that’s a good distinction. You know, we don’t have to
have them do it when they’re inpatient, or administering in the ER, but if we’re writing for them to go home, and you still have that. – It’s a good point. So, another informational. I think at 11 o’clock today, the board of medicine is having, there’s a video conference, and they’re talking about some of the, what would you call it, the consequences of
not following this law. So, I would invite you
to take a look at that. It’s a video that’s going
to be presented today. I think we’ll get you that citation. They’re talking about
some of the consequences for docs who are, I
guess, who are identified as not following this, with, I think, five different levels of
sanctions, or five different disciplinary responses
as it sits right now. But it’s still being discussed, I think, and that’s part of what
that video is, is about. So, a lot is still emerging, and here we are on the,
is it January the third? So. – How about sleep. Does anybody have any
suggestions for sleep? For people who have… We have a ECHO sleep
clinic that we, that we’ve already gone through. And that’s already been
recorded and available. Does anybody have any suggestions for your patients with sleep issues? – We just talk about sleep hygiene, and give handouts for that,
and try to offer, you know, teas and melatonin. If there’s significant
other concerns for sleep, we try to get them
evaluated for sleep studies. – Wasn’t there a question
about sleep earlier? Or did we get interrupted? – [Troy] Yeah, Dr. Postman. I think rose far enough. – [Dr. Postman] And last
time, Dr. Lewandowski, when you were talking about sleep. – Yes, sir. – [Dr. Postman] And I don’t believe you got into the area of blue light before sleep. I don’t recall you
mentioning that, did you? – No, we didn’t. I didn’t talk about that
section of sleep treatment. But certainly, the
luminous, the light therapy is a very, and I think, proven treatment for different kinds of sleep conditions. Certainly. – [Dr. Patterson] In
the literature there’s a lot of information
about avoiding computers, mobile phones, that
sort of thing for about three hours before intended sleep. And also, it would be nice, maybe, to get a little bit more into that at some point, if you have time. But also, it’s interesting
that, I don’t know about the other phones, but on iPhones, there is actually a
setting called Night Shift, where you can change the color pattern. You can adjust the, when you
want the default to come on at 7 p.m. to go off at 7 a.m., where you shift the light from blue light to warmer tones, and the, the person operating
the phone can actually control not only the on/off times from the default,
but they also can change the brightness intensity. So anyway, I thought maybe
in some point in the future if you ever get back
to talking about sleep, it might be an interesting
thing to include. – That’s a great point. A colleague of mine, Dr. Michael Accia, has even taken that one step further. There is a, he’s purchased a screen that he put over his iPhone, and even his computer. But also dampening some of
the damaging light rays, and he says he has found
that to be helpful too. So, excellent topic, and I think… – [Dr. Patterson] I know Mike
and I were working together some years ago about,
because of his interest in allergenic, or some allergist. But my understanding is that might be a nice
thing for your computer, but not necessary for an iPhone. It’s really not necessary,
because the feature is essentially built in. – Interesting. Yeah. Which means that with one click, you can implement that therapy. – [Dr. Patterson] You not
only can implement it, but as I said, you can
control the on/off time and the intensity of brightness, or at least of warmth. – Great. – [Dr. Patterson] Mostly
the intensity of brightness and the warmth of the screen. – And I also think I have a book for you. You ever do that question on
Mel and Potty scored correctly. Oh, I’m sorry, oh, okay. – [Troy] Alright, just a
minute after 9 o’clock. Any other questions for our panel today? – Well, thank you all for being here. We’re going to be doing this
in the next couple of weeks. – [Troy] January 17th, yep. – 17th, okey-dokey. If you need anything, please
don’t hesitate to contact us. My contact information
is in the PowerPoint. And Dr. Lewandowski is always here too. – Yeah, thank you, guys. Have a great couple weeks. – Thank you so much.