A Look at Pain and the Opioid Epidemic in Pennsylvania

the OURNAL Jof the Pennsylvania Osteopathic Medical Association September 2017

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College of Osteopathic Medicine • School of Pharmacy • School of Dental Medicine School of Graduate Studies • Masters/Post Baccalaureate Campuses in Erie and Greensburg, PA and Bradenton, FL THE September 2017 / Vol. 61, No. 3

association officers Contents President — George D. Vermeire, DO President-elect — Joan M. Grzybowski, DO, FACOFP Vice President — Pamela S.N. Goldman, DO, MHA, FACOI Secretary/Treasurer — William A. Wewer, DO, FACOFP 4 From the Editor’s Desk Immediate Past President — Anthony E. DiMarco, DO, FACOFP — Diana M. Ewert, MPA, CAE Chief Executive Officer 5 Out of My Mind editorial staff Editor-in-Chief — Mark B. Abraham, DO, JD 6 LECOM Dean’s Corner Editor Emeritus — Leonard H. Finkelstein, DO, FACOS Managing Editors — Diana M. Ewert and Brenda R. Dill Layout — Brenda R. Dill 7 PCOM Dean’s Corner editorial consultants Chairman: Mark B. Abraham, DO, JD 8 A Student’s Voice — LECOM Anesthesiology: James T. Arscott DO, chairman Pain Mgmt: Harry Glass, DO; Jan T. Hendryx, DO; Christopher A. Davis, DO Acupuncture: Gregory W. Coppola, DO, Silvia M. Ferretti, DO; Jan T. Hendryx, DO 9 A Student’s Voice — PCOM Dermatology: Anthony Benedetto, DO; Richard Johnson, DO; Jana Lynn Ebbert, DO Family Practice: Marc A. Monaco, DO, chairman Geriatrics: Katherine E. Galluzzi, DO; Robert A. Weisberg, DO, co-chairmen Medicine: Joseph M.P. Zawisza, DO, chairman 10 About the Authors Alcoholism, Drug Addiction, Toxicology: Joseph M. Kosakoski, Jr., DO, chairman Allergy & Immunology: Timothy Craig, DO; James DeAngelo, DO; Timothy McCloskey, DO Cardiology: Peter F. Stracci, DO 10 Index to Advertisers Critical Care: Michael A. Venditto, DO Emergency Medicine: Gary W. Welch, DO, chairman Gastroenterology: Richard E. Moses, DO, J.D.; Glenn S. Freed, DO General Internal Medicine: Joseph M.P. Zawisza, DO; Pamela S.N. Goldman, DO 11 Guest Column Infectious Diseases: Robert S. Jones, DO; David H. Loughran, DO; Amanda E. Wehler, DO Metabolic Diseases: Jeffrey S. Freeman, DO; James E. McCann, DO; Marc A. Vengrove, DO Evaluating the Whole Person when Nephrology: Michael L. Levin, DO; Edward J. Zaloga, DO Deciding on Opioid Inclusion Neurology: Jeffrey J. Esper, DO Oncology/Hematology: John Conroy, Jr., DO; Carlin McLaughlin, DO; Jeffrey Stevens, DO Amy L. Davis, DO Pulmonary: Gilbert E. D’Alonzo, Jr., DO; Michael A. Venditto, DO Urgent Care: Mark B. Abraham, DO; Glenn R. Ortley, DO Obstetrics & Gynecology: Ralph E. Aldinger, Jr., DO, chairman 13 Guest Column Human Sexuality: Richard A. Ortoski, DO Osteopathic Principles & Practices: Alexander S. Nicholas, DO; Evan A. Nicholas, DO, co-chairmen Doctors Critical in the Fight Against Opioids Pathology: Amanda E. Wehler, DO Pediatrics: Michael E. Ryan, DO, chairman Pennsylvania Attorney General Josh Shapiro Allergy & Immunology: Timothy J. Craig, DO; Timothy J. McCloskey, DO Cardiology: Harry P. Flanagan, III, DO Neonatology: Steven M. Snyder, DO 15 CME Quiz Physiatry/Rehabilitative Medicine: Silvia M. Ferretti, DO, chairman Psychiatry: Timothy S. Mitzel, DO; Elizabeth A. Ramsey, DO Radiology: Richard M. Purse, DO, chairman Diagnostic Radiology & Nuclear Medicine: Richard M. Purse, DO Invasive Radiology: Terry N. York, DO Radiotherapy: Ellen M. O’Mara, DO; Desiree Lerro, DO Ultrasonography: David A. Levin, DO Rheumatology: Richard A. Pascucci, DO Sports Medicine: Patrick F. Leary, DO, chairman Connect with POMA on Social Media — Surgery: Theodore S. Eisenberg, DO, chairman Cardiovascular: Joseph J. Stella, DO Click on the Icons or Search for Us with Our Handles General Surgery: Theodore S. Eisenberg, DO; Steven Katz, DO Neurological: Richard B. Kanoff, DO Ophthalmology: Elena R. Farrell, DO @POMADOs Orthopedics: John J. McPhilemy, DO Otorhinolaryngology: Carol L. St. George, DO Plastic & Reconstructive: Sherman N. Leis, DO @POMA_DOs Proctology: Jerome A. Greenspan, DO Urologic: Laurence H. Belkoff, DO; George T. Zahorian, III, DO Pennsylvania Osteopathic Trauma: Susan M. Baro, DO; Jan A. Olenginski, DO; Regan P. Shabloski, DO Medical Association (POMA)

The Journal of the Pennsylvania Osteopathic Medical Association (ISSN 0479-9534) is published four (4) times a year, in March, June, September and December, as the official publication of the Pennsylvania Osteopathic Medical Association, Inc., 1330 Eisenhower Boulevard, Harrisburg, PA 17111-2395. Subscription $20 per year, included in membership dues. Periodicals postage paid at Harrisburg, PA, and additional mailing offices. © 2017 by the Pennsylvania Osteopathic Medical Association. All material subject to this copyright may All original papers and other correspondence should be directed to the editor at the above address. Telephone be photocopied only for noncommercial educational or scientific uses. Permission to reprint articles or (717) 939-9318 or, toll-free in Pennsylvania, (800) 544-7662. POSTMASTER: Send address changes to The portions of articles may be obtained by writing to the managing editor. Proper credit and copyright notice Journal of the Pennsylvania Osteopathic Medical Association, 1330 Eisenhower Boulevard, Harrisburg, should accompany all reprinted material. We reserve the right to edit material submitted for clarity and PA 17111-2395. length. Opinions expressed by individuals through the pages of this magazine do not necessarily represent the official position of the Pennsylvania Osteopathic Medical Association. FROM THE EDITOR’S DESK Mark B. Abraham, DO, JD

As we continue the health care debate in the ultimately spent a short time in prison as a United States, one particular conversation con- result. That physician did beat the problem tinues to stand out and grow. Whatever it is, and is now practicing successfully. When that a(n) problem, issue, concern, crisis, epidemic, physician spoke to the class, the students put (insert your own word based upon your level away laptops and such devices. There were no of concern and view of severity), it is not go- side conversations. They were all paying close ing away. As such, this issue of the Journal is attention. None were asked to do so. They real- dedicated to discussing the opioid epidemic. ized the importance of what was being taught You will read the perspectives from the to them by that doctor at that very moment. Deans of PCOM and LECOM and how they Did his story mean there would always be a are addressing the issue as their physicians not happy ending? Of course not. But, it was the Mark B. Abraham, DO, JD only treat patients in their health settings, but start of the conversation for them. Finding a Editor-in-Chief also train the next generation of physicians. way to open the dialogue is a key component Our students, the future of medicine, have to continuing to raise awareness and hope- voiced their thoughts about about treating fully, ultimately, put an end to the issue. patients with empathy and dignity, acknowl- Looking forward, our December/Winter edging that treatment is possible and we as issue will focus on the future of medicine and physicians are part of the solution. A palliative the role professional organizations, especially medicine physician shares her thoughts on POMA, will play in helping physicians and the treatment of pain and how to best help patients navigate the ever-changing world of patients suffering from chronic pain in the medicine and health care. Just as we have a current opioid-sensitive environment. As you submission this time from the Attorney Gen- may expect, there are many references in her eral and a palliative care physician, I hope piece highlighting the benefits of osteopathic that we will have other submissions from our manipulative medicine. members. I invite you to submit an article. We also have a guest submission from The If you know someone, perhaps a lawmaker, Honorable Josh Shapiro, Attorney General of person in public policy, public health or even the Commonwealth of Pennsylvania. Attorney an executive in a health-related organization, General Shapiro, whose father is an osteopath- encourage the person to write a piece. Ones ic pediatrician in Montgomery County, shares appropriate for submission will ultimately be his thoughts on how to address the issue from published. And while I cannot guarantee every multiple angles, including through involving manuscript will be printed in a specific edition, our governmental leaders, whether prosecu- it is always better to have more from which to tors, legislators or executive leaders. choose than less. The opioid epidemic is so wide reaching Similarly, even though this issue is about that unfortunately, most of us know a col- opioids, it is the beginning of the discussion league, have a friend, former classmate or and not the end. I hope that you will read this possibly family member who has been af- issue and that we will then hear from you. fected by the opioid problem. Even though Share your thoughts and comments whether so many people are touched by this issue, the it concerns your views, thoughts on opioids conversation is still lacking. When I taught the and the current environment, or just your medical jurisprudence course at UMDNJ-SOM opinion of the Journal. I welcome the “Letter (now Rowan University-SOM) in Stratford, to the Editor.” New Jersey, my students learned from DEA I hope you have all enjoyed your summer. Diversion agents, lawyers from the New Jersey State Attorney General’s Office, and a physi- Collegially, cian who had a substance abuse problem and Mark B. Abraham, DO, JD

4 / September 2017 The Journal of the POMA OUT OF MY MIND Samuel J. Garloff, DO

“The further a society drifts from the truth, About 100 years ago, misuse of opioids and the more it will hate those who speak it.” opiates was so common that the Harrison — George Orwell Narcotics Tax Act was enacted. The act was approved on December 17, 1914. It involved “a The joy plant. Over 5,000 years ago, the special tax on all persons who produce, import, Sumerians in lower Mesopotamia cultivated manufacture, compound, deal in, dispense, opium. It was known as Hul Gil, aka, the joy sell, distribute, or giveaway opium or coca plant. leaves, their salts, derivatives, or preparations In 1840, Mrs. Charlotte N. Winslow, a mid- and for other purposes.” wife, prepared a tonic to market to children and Secondary to the Boggs Act of 1951-2 and infants to help relieve the pain of teething and the Narcotic Control Act of 1956, mandatory allow them to sleep. It consisted of morphine sentences for drug-related offenses, including Samuel J. Garloff, DO sulfate, sodium carbonate, spirits foeniculi (al- marijuana, were set. A first marijuana posses- cohol) and aqua ammonia. It was sold as Mrs. sion offense carried a minimum sentence of 2 Winslow’s Soothing Syrup, it became known as to 10 years with a fine up to $20,000. “baby killer.” In spite of condemnation by the Obviously the use of these narcotic prepa- AMA, it remained on the market until 1930. rations never stopped. They are incredibly John Stith Pemberton was a Confederate effective for pain management. In fact, the Lieutenant Colonel in the Civil War. He was in- Joint Commission issued standards for pain jured during the Battle of Columbus, receiving management control of hospitalized patients. a saber wound to the chest. As a result he, and In a JAMA article from July 26, 2000, the Joint thousands of other civil war veterans, became Commission stated “the pain management addicted to morphine. He found relief with a paradigm is about to shift.” Other hospital medicinal drink called Vin Mariani made in accreditation programs immediately followed France. This French wine contained coca leaf. the example of the Joint Commission and He then developed Pemberton’s French Wine wrote changes to their pain management Coca, made with kola nut, damiana, coca standards. leaves and wine. It became an instant success. There are many who say as a result of the It was advertised to help patients withdraw accreditation standards, drug abuse exploded from morphine, invigorate their neurologic in this country. There is little doubt that since systems, etc. these standards started, drug abuse has grown. Unfortunately, in 1886 the city of Atlanta Is this cause and effect or coincidental? The enacted prohibition. As a result he could no joint commission and other accrediting bodies longer market his French Wine Coca. He then say that this is due to misinterpretation of their created a temperance drink which we now guidelines. I for one will be happy to see the call Coca-Cola. It consisted of coca leaves, kola day when smiley faces disappear from every nuts, carbonated water and a sweetened syrup, emergency room and patient chart. which is still proprietary. It was marketed as There is an additional component that is of- “delicious, exhilarating, refreshing and invigo- ten overlooked by all involved. It is not simply rating” as well as having “the valuable tonic that misuse of opioid-like substances but, the and nerve stimulant properties of the coca concurrent and additional misuse of benzodi- plant and kola nuts”. To this day, expended azepines leading to an escalation in prevent- coca leaves are imported into the United States able deaths. It is time for pain management by a firm in New Jersey. Coca-Cola is then able clinics to become truly that, a clinic where a to purchase the leaves, which are now cocaine- patient with pain can be seen and be given safe free, to add to their syrup. Once this process and satisfactory alternatives to prescription is complete these leaves are destroyed under drugs. Obviously we see the future. Will we as presence of federal officials. This beverage com- physicians be brave enough to shape it? pany and its importer are the only companies allowed to bring this leaf to the United States. “If this is the best of all possible worlds, what They asked for, and received, a legal exception are the others like?” to policy to be allowed to do so. — Candide

The Journal of the POMA September 2017 / 5 LECOM DEAN’S CORNER

Lake Erie College of Osteopathic Medicine

We possess the power to prevent thousands of The Lake Erie College of Osteopathic Medi- deaths from opioid overdoses. So why haven’t we cine (LECOM) Integrative Medicine physicians done so? manage pain without opioids using osteopathic treatment, acupuncture, and other non- With almost a 200 percent increase in opioid medication treatments, including advanced overdoses since 2000, it is abundantly clear that aqua healing. Many of these therapies are the treatment system as it stands is not working, derived from osteopathic principles. and Americans, from all walks of life are dying Undoubtedly, chronic pain is common, as a result. Many of those who have found multidimensional, and highly individualized; themselves becoming opioid dependent have and its treatment can be challenging for health Silvia M. Ferretti, DO become so after suffering an injury or enduring care providers as well as for patients. OMT is LECOM Provost, chronic pain. As a result, drug overdoses now a comprehensive system of evaluation and Vice President and outpace car crashes as the leading cause of ac- treatment that is designed to achieve and to Dean of Academic Affairs cidental death in the United States. maintain health by restoring the normal body Regrettably, America is in the midst of an functions. It is important that the full range of epidemic of prescription and illicit opioid over- therapies be brought to bear upon the treat- dose deaths. In 2015 alone, more than 30,000 ment of chronic pain if the field of medicine is people perished as the result of the overuse or going to improve overall success rates. Integra- the improper use of such medications. Each tive Medicine, such as that practiced by physi- day, more than 40 Americans die from prescrip- cians throughout the LECOM system, offers a tion opioid overdoses. The amount of opioids broad, healing-oriented approach to medicine prescribed and sold in the United States has that emphasizes a patient-doctor partnership; quadrupled since 1999 with opioid-related one which takes into account the whole person, deaths numbering more than 168,000, yet there including all aspects of the patient’s lifestyle. has not been an overall change in the amount It embodies the ability of the practitioner to of pain that Americans report. While prescrip- offer therapeutic options consistent with the tion opioids indeed can serve well as an ap- patient’s belief system that are predominantly propriate part of pain management and new non-surgical and non-medication focused. In- federal guidelines seek to improve the safety of tegrative options reveal high-quality research, prescribing and reducing harm associated with patient safety, effectiveness — and they offer opioids, there is another option to treat pain: reduced adverse effects in clinical practice. Osteopathic Manipulative Treatment. Indeed, the time-honored and effective os- LECOM advocates for opioid recovery teopathic principles of whole-body health care methods that actually can break down barriers offer a comprehensive approach to patient well- to treatment, so that people who want help can ness. These principles account for the whole- receive treatment that works. ness of the patient — complete in mind, body Endeavoring to stem perhaps one of the and spirit. Understanding this aspect of health worst public health drug crises in decades, care allows physicians to think broadly and use the federal government Centers for Disease techniques and treatments that extend beyond Control (CDC) recently published the first the curative default position of prescribing pills. national standards (guidelines) for prescrip- The use of that which many allopathic doctors tion painkillers, recommending that physicians may term alternative medicine has offered try pain relievers, such as ibuprofen, before superlative results for many patients. prescribing the highly addictive pills; and if Perhaps, the rest of the world is just now doctors do prescribe such opioids, that they learning that which osteopathic physicians give most patients only a limited supply. have known from the start: that whole-person While all of the discussion regarding opioid treatment entails using a wide array of effective limits and new guidelines may be fruitful, the treatment options that best facilitate the end most fruitful option would be never to have result — a healthy and pain-free patient. relied upon such medications in the first place. Fraternally, Enter Osteopathic Medicine! Silvia M. Ferretti, DO

6 / September 2017 The Journal of the POMA PCOM DEAN’S CORNER

Philadelphia College of Osteopathic Medicine

The illegal use and misuse of opioids con- addicted to opioids. According to a study tinues to be a public health crisis. According conducted by Massachusetts General Hospital to the National Institute on Drug Abuse, since Center for Women’s Health, the prevalence of 2012, heroin overdose deaths have increased women admitted to hospitals nationwide for five-fold, and prescription opioid deaths have obstetric delivery and also identified as abus- increased three-fold. ing or being dependent on opioids increased As medical educators training the next more than 127 percent between 2008-2012. generation of physicians, we must be vigilant The authors of that study found several about how we educate our students to treat complications, including maternal cardiac ar- patients who may be struggling with opioid rest, intrauterine growth restriction, placental addiction. While opioids can be useful in pain abruption, preterm labor and stillbirth, were Kenneth J. Veit, DO management, it is critical our students know more common in women using opioids dur- PCOM Provost, Senior Vice the safest, most effective ways to prescribe ing pregnancy. President for Academic Affairs and Dean those medications. Pregnant women should not be overlooked The PCOM curriculum is imbued with when discussing opioid use. To that end, in courses on safe prescribing methods, and, is the 2016-2017 academic year, Joanne Kakaty- right on target with the Centers for Disease Monzo, DO, chair of Ob/Gyn at PCOM, added Control and Prevention’s (CDC) Guidelines for the topic of opioid use in pregnancy to the Prescribing Opioids for Chronic Pain. Those curriculum of the Reproductive Genitouri- guidelines include opioid selection; initiation nary and Obstetrics, Gynecologic Medicine or continuation of opioids for chronic pain; course. opioid selection, dosing, duration, follow-up During that course, students learn about and discontinuation. Additionally, and of ut- all aspects of the opioid crisis. Those topics most importance, is addressing risk and harms include the neurobiology of addiction, signs of opioid use. and symptoms of substance abuse in pregnant For example, in the clinical and basic neu- women, and recommendations on how to roscience courses, our students learn not only communicate with their patients on the risks about the structure and function of the human of substance abuse disorder to both mother brain, but also psychiatric and behavioral and baby. Students also learn treatments that medicine. This includes substance abuse disor- can help wean those patients off substances, ders; pain and pain management techniques, which include opioids. with a focus on the emotional toll of chronic When we talk about combating the opioid pain and it’s relation to addiction. The course crisis, it is imperative that we consider all also includes lessons on pharmacological segments of the population. For our future treatments and precautions, including those doctors, arming them with the knowledge related to opioids, among other therapeutics. that addiction can strike anyone, anywhere, However, in the larger, national conversa- at any time, will prepare them to be effective tion about opioid use and the addiction crisis, and conscientious health care providers. there is a segment of the population that has Fraternally, been overlooked — the pregnant woman Kenneth J. Veit, D.O.

The Journal of the POMA September 2017 / 7 A STUDENT’S VOICE — LECOM Jordan M. Spencer, OMS-IV

A Student’s Musings on Addiction

Over the last few years, the opioid epi- States, were asked about their drugs of choice, demic has become a buzzword within the the undeniable answer was opioids (both medical community. Bills have been passed prescription and heroin). In my unofficial and legislation has been made, worried orga- surveying over the year, never had any of the nizations and medical facilities have created patients recovering from heroin use ever start policies to limit the distribution, more effec- with heroin. tive communication between pharmacies has Sad stories involving heroin always in- been established. And in all this commotion, volved the humble beginnings with prescrip- I fear that in many respects the epidemic has tion medications. At times it was stories of Jordan M. Spencer become nothing more than a buzzword, or an having a surgery or medical procedure which LECOM OMS-IV all-to-often said phrase that has begun to fall provided them their first bottle of pills. Some on deaf ears. One of those fads in the medical would have a memorable introduction at a world that will come and go. I urge you to not high school or college party and never look let this be the case. back. And others had been prescribed opiates While this is a multi-faceted issue and for debilitating pain and were never been able there are many to whom we can point our to stop, even when the pain had subsided, as fingers, I do not believe placing blame on any a new pang of withdrawal symptoms accom- one group will accomplish anything. It will panied the bookends of their now finely tuned only raise up defenses and cause contention intake schedule. These pills were obtained between hospitals, legislators, families and so through a limitless number of locations – from forth. However, that being said, as physicians medicine cabinets of family members who are I believe it is important for us to recognize the no longer taking them, to stolen morphine role that we play, not only in the issue at hand, patches of grandmothers with cancer, the op- but in the solution. portunities were endless. I come from a rather interesting background As doctors we are trained to help, we are as a student to speak on this issue. I grew up trained to heal, we are trained and indeed in the state of New Hampshire, which was have a duty to do whatever we can to ease the number one state per capita for alcohol the pain of disease and work to fight sickness and heroin abuse while I lived there. When within our patients. I fear however in our the high school 30 minutes way was given overzealous efforts to temper pain, we have a survey regarding drug usage, they were found ourselves causing the disease of addic- comparable to national averages until the tion. While this has never been the intent, it is question of heroin, where nearly two-thirds of a sad reality that we must be aware of. the students answered that they took heroin One of the consistent and troubling pat- regularly (2 times or more every week). I was terns I found with my patients at the inpatient fortunate that both the high schools I attended facility was an all too common story… Upon were not nearly as devastated by this drug, the first hint of a prescribing physician real- however I will say that prescription drug abuse izing a patient may have a dependence issue, was rampant, including opiates. ties were cut and patients were encouraged Drug abuse has become a topic of interest to find treatment options somewhere else. For to me (I hope to dedicate a large part of my our patients at the rehab facility, this was often future practice to addiction medicine) and times the breaking point between functional when I entered my undergraduate education addiction and an all-encompassing disease I found myself in a research facility working which would eventually affect their social, with drugs of abuse on animal models, and occupational and personal lives. worked as a psych-tech at an inpatient drug At the time, I did recognize many of the facility. This opportunity gave me a first-hand reasons why a physician would do this and intimate knowledge of the epidemic. When I feel I understand even more now as a stu- our patients, who came from across the United dent of medicine. Within our current litigious (continued on page 14)

8 / September 2017 The Journal of the POMA A STUDENT’S VOICE — PCOM Elisa Giusto, OMS-IV and Olivia Hurwitz, OMS-IV

As we move through our clerkship years, end up acting as yet another barrier to patient we have the opportunity to work with many care. These are just some examples of why types of patients, physicians and students, drug recovery programs, and the patients which can be as beneficial to our education as themselves, end up getting overlooked by fed- the medicine we learn. This exposure allows us eral and state-level systems, even those which to understand the different styles of practicing are supposedly put in place to help them. medicine, as well as different attitudes that Perhaps the more problematic barrier to can either help or harm patients as much as patient care, as evidenced throughout our any medical procedure. Unfortunately, treat- clinical clerkships, however, is on an individual ing patients with drug addictions can make level, by how physicians or other health care students, physicians and other health care pro- professionals interact with patients who are viders act in ways that can be very harmful to addicted to drugs. Most people assume that Elisa Giusto PCOM OMS-IV patients seeking (or not seeking) recovery. This the worst way to act towards patients with problem can be seen both systemically, at the drug or alcohol addictions is to be judgmental level of governmental and non-governmental — to blame them for not being able to quit, to organizations, and individually, through condemn them for using substances in the first health care professionals interacting directly place, to stereotype them as criminals or liars. with patients. These are, of course, inappropriate attitudes to The U.S. Drug Enforcement Administration hold towards these patients. However, while reported that there were 4,642 drug fatalities spending time on the inpatient detox unit in Pennsylvania in 2016, a 37 percent increase during a psychiatry rotation in West Phila- from 2015. Prescription or illegal opioids, such delphia, it quickly became apparent that the as heroin, were the cause of 85 percent of these most harmful attitude towards patients who deaths. Governor Wolf’s administration is are addicted to drugs is not judgment, rather addressing the crisis by creating 51 locations it is pity. To victimize these patients with a Olivia Hurwitz in a “Center of Excellence” network to con- simpering “they are just a product of their PCOM OMS-IV nect people to addiction treatment programs. circumstances” and a “poor you” attitude is to Unfortunately, chronic understaffing and deny their agency and diminish their person- underfunding at the Department of Drug and hood. It gives them nothing, and only serves Alcohol Programs is stalling the state’s ability to take away the very self-determination that to fight the opioid epidemic. Auditor General is vital to surviving the recovery process. This Eugene DePasquale released a report last year is not to say that it is wrong to acknowledge recommending a licensing fee on drug treat- that some people’s lives have been more dif- ment centers to help bring money into the ficult than others’, but if we treat all patients agency. Meanwhile, the Department of Correc- addicted to drugs as though only bad luck, and tions monitors just one of its seven addiction not personal choice, is what got them there, treatment program for effectiveness, but this how can we expect them to hold themselves to information is limited to mapping the rate of a higher standard? Treating patients effectively recidivism over time, and not necessarily the and empathetically may sometimes require a client’s response to the programs themselves. physician to foster in those patients a sense of The auditor general’s report recommended resilience, not to pity them, but to reinforce evaluating all of its programs, including in them the idea that they once were strong the agency’s medication-assisted treatment enough to be clean and sober, and that they programs, with an established routine evalu- can be strong enough to get there again. ation. The report also recommended that the Department of Health write regulations to en- Source: sure Pennsylvania physicians safely prescribe APA: Pennsylvania told to improve addic- buprenorphine-related medications, as such tion program evaluation. U.S. News & World regulations were previously lacking. Although Report, July 13, 2017. https://www.usnews.com/ these recommendations are well-intentioned, news/best-states/pennsylvania/articles/2017-07-13/ it will be interesting to see if any of them are pennsylvania-isnt-evaluating-addiction-programs- able to become reality, and whether they will audit-says

The Journal of the POMA September 2017 / 9 ABOUT THE AUTHORS

Amy L. Davis, DO, MS, FACP, FAAHPM, is organizations focused on improving and pro- the author of "Evaluating the Whole Person when viding quality medical care and on substance Deciding on Opioid Inclusion." She is a board abuse in the setting of serious illness. certified subspecialist in hospice and palliative medicine with a private palliative care practice The Honorable Josh Shapiro, author of in the Philadelphia area. She is also a clinical "Doctors Critical in the Fight Against Opioids," Amy L. Davis, DO assistant professor at Drexel University School is Pennsylvania's Attorney General, the Com- of Medicine. Dr. Davis graduated from the monwealth's top lawyer and chief law enforce- Philadelphia College of Osteopathic Medicine ment officer. Sworn into office in January 2017, with DO and Master of Science (Neuroanato- directing an aggressive fight against the heroin my) degrees. She completed an internship at and opioid epidemic, including treatment for the University of Medicine and Dentistry of those suffering from addiction, is amongst New Jersey – School of Osteopathic Medicine/ his top priorities. Attorney General Shapiro Kennedy Health System, an internal medicine previously served as chairman of the Pennsyl- residency at Pennsylvania Hospital and a vania Commission on Crime and Deliquency, palliative medicine fellowship at the Mount chairman of the Montgomery County Board Sinai Medical Center in New York. A fellow of Commissioners and a State Representative of the American College of Physicians and the for Pennsylvania's 153rd House District. A American Academy of Hospice and Palliative graduate of the University of Rochester and The Honorable Josh Shapiro Medicine (AAHPM), Dr. Davis is serves on Georgetown University Law Center, he is a several national and regional committees of member of the Pennsylvania Bar Association.

Index to Advertisers

Extra Step Assurance...... 15 Lake Erie College of Osteopathic Medicine...... cover 2 NORCAL Mutual Insurance Company...... cover 4 Physicians’ Health Programs...... 10 POMPAC...... 15

Attention Writers... The Journal of the POMA is seeking professional articles from YOU! The December 2017 issue will focus on the future of medicine and the role professional organizations, especially POMA, will play in helping physicians and patients navigate the ever-changing world of health care. Submissions welcome from POMA members and the public!

E-mail entries to the JPOMA Editor c/o [email protected].

10 / September 2017 The Journal of the POMA Guest Column Evaluating the Whole Person when Deciding on Opioid Inclusion

While early data cannot be directly com- have difficulty differentiating physical from pared with more recent figures because of nonphysical pain but are suffering regardless. by Amy L. collection differences, the Substance Abuse There is a growing paradigm shift viewing Davis, DO and Mental Health Services Administration’s people requesting pharmaceutical-based pain (SAMHSA) National Survey Reports suggest treatment as “comfort seekers” rather than as there was a 2.2-fold increase in overdose “drug seekers;” this is almost always a more deaths from all drugs from 2002 to 2015, when accurate description of their goal. more than 52,000 people died.1 The number Substance use disorders (SUDs) are physi- of people dying from heroin and illicit fen- cal conditions characterized by the continued tanyl continues to skyrocket throughout the use of a substance despite detrimental effects, United States. However, the number of such compulsive use or behaviors to obtain it, and deaths from prescription opioids has gener- a pre-occupation with its use for nonmedical ally stabilized since 2011 with 17,536 deaths purposes. Because these behavioral compo- in 2015.1 Widely suggested reasons for this nents are more prominent than their physical include improved prescriber education, de- causes and our culture puts a stigma on mental creased prescription opioid availability, and illness, those who admit they are suffering their subsequent increased cost. Heroin is now from this condition (or had in the past) often considerably cheaper to purchase in a growing become isolated and judged negatively by so- number of communities than, for example, ciety. Healthcare professionals and laypeople oxycodone.2 Unfortunately, heroin tends to alike should view SUDs as physical illnesses also be more lethal. requiring individualized evidence-based care, Drug-related aberrant behaviors can be not character weaknesses; no one chooses to viewed as falling into two categories: those have a SUD. Diversion also falls into the non- related to medical or nonmedical use. Pseudo- medical use category and may or may not stem addiction3 can occur when pain treatment re- from an underlying SUD. sults in insufficient relief, causing the person to Chronically uncontrolled, physical pain have escalating analgesic demands that are not can negatively affect hormonal balance, renal adequately addressed and subsequent behav- function, mental processes and neurotrans- ioral changes to convince others of the pain’s mitter balance, immunity, and other body severity. A bilateral crisis of mistrust becomes systems.5 The whole person, individualized established. The aberrant behaviors cease with approach, utilizing multimodality therapies adequate analgesia, but the person’s loss of with the highest expected benefits and the trust in prescribers may linger. Another ex- lowest risks expected for that person, is most ample in the medical use category is chemical effective in managing physical and non- coping.4 This is characterized by a pattern of physical pain. There are a variety of validated maladaptive coping through drug use or the screening surveys to assess someone’s risk belief that medications fix everything. People for aberrant behaviors, developing or having with this tendency often feel stress physically, a SUD, or diversion, and most are available such as with headaches, gastrointestinal symp- for free. While there is limited literature dem- toms, and/or “total body pain.” They may use onstrating efficacy, other tools, such as using the medications to treat both their physical and a restricted medication bilateral agreement, nonphysical pain and in ways outside of the urinary drug testing, and/or pill counting as prescriber’s recommendations. However, they part of a broader ongoing discussion with the do not have an addiction. “Chemical copers” person likely also have clinical utility. These

The Journal of the POMA September 2017 / 11 should be chosen based on the individual’s serious illness adds complexity, the individu- unique situation and may change with evolv- alized, whole person multimodality approach ing circumstances. Open communication is can be adapted to the needs of palliative care quintessential. patients. Legislation of medical care needs to This type of whole person approach can also be cognizant of the diverse needs among those easily be applied to those requiring restricted treated with opioids and other restricted medi- medication for symptom management in the cations and allow prescribers the flexibility setting of concurrent serious illness (palliative needed to individualize treatment based on care). Fewer treatment options may be avail- their expertise. able due to physiologic changes, prognosis, rapid escalation of symptom intensity, drug- References drug interactions between non-opioid alterna- 1. Center for Behavioral Health Statistics tives and disease-directed drugs, and other and Quality. (2016). Key substance use and related issues. Nonetheless, consideration of mental health indicators in the United States: non-restricted medications, as adjuvants or Results from the 2015 National Survey on alternatives, and a multimodality care plan Drug Use and Health (HHS Publication No. maximize benefits while minimizing risk and SMA 16-4984, NSDUH Series H-51). Retrieved negative effects. Consultation with a pallia- from http://www.samhsa.gov/data. Prior reports tive care specialist can be helpful in complex are also available. Note: There was a 2.8-fold cases, regardless of the person’s goals of care. increase in the total number of overdose Caregivers and loved ones should also be con- deaths from heroin, opioid analgesics, and sidered when assessing risk, especially when illicit synthetic opioids from 2002 to 2015. someone has significant debility or reliance 2. Gupta S: Unintended consequences: on others. Tools too should be individualized. Why painkiller addicts turn to heroin. CNN For example, if someone lacks understand- Online, Updated June 2, 2016. Retrieved from ing or would be harmed by participation in a http://www.cnn.com/2014/08/29/health/gupta-un- restricted medication agreement discussion, intended-consequences/index.html, Accessed July substitution with the caregiver(s) should be 28, 2017 and Carey, B: Prescription painkillers considered. Just as serious illness affects people seen as a gateway to heroin. New York Times. among all socioeconomic strata, communities, Updated online February 10, 2014. Retrieved educational backgrounds, and other cultural from https://www.nytimes.com/2014/02/11/health/ divisions, SUDs too have no such boundaries. prescription-painkillers-seen-as-a-gateway-to- When these become concurrent issues, special- heroin.html, Accessed July 28, 2017. ist consultation and even ongoing inclusion on 3. Weissman DE, Haddox JD: Opioid the healthcare team should be considered to pseudoaddiction — an iatrogenic syndrome. maximize symptom management and func- Pain. 1989;36(3):363-366. tion and minimize suffering. 4. Smith H, Passik S: “Chemical Coping.” Aberrant behaviors demonstrated by people Pain & Chemical Dependency. New York: Oxford with pain should be viewed as “red flags” that University Press, 2008, 299-302. require additional assessment to determine 5. Berry PH, Covington EC, Dahl JL, et al. the etiology, and SUD should not be assumed. Pain: Current understanding of assessment, Viewing those seeking pharmaceutical-based management, and treatments. American Pain pain treatment as “comfort seekers” is an Society. Dec. 2001: 1-101. important paradigm shift. While concurrent

12 / September 2017 The Journal of the POMA Guest Column Doctors Critical in the Fight Against Opioids

In 2016, over 4,600 Pennsylvanians suffered manufacturers to determine if their marketing fatal overdoses, a 37 percent increase from the and sales practices have violated the law and by Pennsylvania year before. Overdose is now the number one helped fuel this crisis. Attorney General accidental killer in Pennsylvania. This epidem- Fourth, the public must help reduce the opi- Josh Shapiro ic, which claims the lives of 13 Pennsylvanians oid supply. There are also tons — literally tons every day, is driven by opioids, including — of opioid medications just sitting around in prescription pain medications, heroin, and our homes, waiting to be abused. In fact, over synthetic drugs like fentanyl. 70 percent of people who misuse prescription As Pennsylvania’s chief law enforcement opioids get them not from doctors or drug official, the opioid crisis is my top priority, but dealers, but from friends and relatives who I know that we cannot simply arrest our way have leftover pills in their medicine cabinets. out of this crisis. We need a multidisciplinary Properly disposing of unused opioid medica- approach that leverages the work of law en- tions will keep them from harming others later forcement, the medical profession, treatment on. My office works with the DEA to set up providers, insurers, community groups and medication drop boxes across the state where citizens across the Commonwealth. people can dispose of their old, unwanted First, we need to go after the dealers who medications. And they work: Pennsylvanians traffic this poison into our communities. Since disposed of over 51 tons of medications at I took office, we have arrested 3 dealers a day these sites in just the last two years. For those and we are working with our partners at the who do not live near a drop box, my office federal, state and local level to halt the supply recently distributed over 300,000 medication of heroin, fentanyl and other opioids on the deactivation bags to pharmacies across the street. state so people can safely get rid of medication Second, we need insurance companies to in their own homes. do their part to reduce the sheer volume of Ultimately, to stem this crisis we need to prescription opioids in our communities. Four reduce supply by attacking the problem at the out of five heroin users start with prescription point of prescription. Doctors and health care opioids, and most Americans cannot afford providers play a critical role in determining a prescription unless their insurance covers how many opioids are available for misuse. it. Insurers act as important gatekeepers to Right now, our nation’s doctors prescribe an the supply of opioids. As a result, earlier this extremely high number of opioids for pain year, I announced a 10-point plan laying out treatment. Even though Americans report the the steps insurers should take to reduce the same overall pain levels as they did in 1999, the flow of opioids, increase access to addiction rate of opioid prescriptions has quadrupled treatment and shift the focus to alternative since then. In 2015, doctors wrote 300 million pain treatments to reverse the rising tide of pain prescriptions, enough to keep every addiction. American medicated around the clock for Third, the makers of opioids manufacture three straight weeks. far too many of these highly-addictive drugs. Unfortunately, there are some doctors, The United States consumes 80 percent of the nurses and other medical professionals who world’s opioid supply despite having only are themselves in the throes of addiction, or five percent of the world’s population. That who use their position to divert opioids from is why I am working with Attorneys General their intended, legal use and siphon them from across the country to investigate opioid off into the black market for their own profit.

The Journal of the POMA September 2017 / 13 While this is a small minority, drug diversion opioids, updated prescribing guidelines and is a growing concern for law enforcement — alternative pain treatments. I am working one my office takes very seriously. We have closely with the Pennsylvania Medical Society doubled the number of diversion arrests so to develop new ways to reach doctors to pro- far this year compared with last year. No one vide them with information and help change should be profiting off of the pain, suffering prescribing habits. and death of others — not manufacturers, not It is going to take an all-hands-on-deck ap- insurers, not doctors. proach to defeat the opioid crisis. Doctors are The vast majority of doctors, though, are on the front lines of this battle just as much as simply trying to do what is best for their pa- law enforcement. I hope that we can continue tients. But prescribing opioids has become the to work together and grow our partnerships default for pain management. The medical so that we can more effectively combat this community is making great strides in educat- crisis. ing doctors about the very serious risks of

LECOM student’s voice (continued from page 8)

society, a physician who has “made an addict” right and bold, tell them your suspicion and and then continued to feed that addiction the reasons why, ask them, and in that same puts themselves at serious risk. The easiest conversation let them know that you are there and most decisive way to mitigate that risk is for them and that you are willing to work with to drop said patient and clearly document the them. Begin a plan for a taper, maybe get bu- reasons why. Not only was this beneficial from prenorphine training. Many of these patients a legal perspective, but it also saves staff and look up to you as their physician, and you may medical personnel from arguably one of the be one of the few constants in their life. Cutting more difficult clinical presentations within the yourself out of their life may just be severing world of medicine. Patients with the disease one of the few fibers keeping the patchwork addiction are very difficult to work with – the stitches of their life together. I do not write this lying, deceit, manipulation, tempers and more to encourage physicians to become enablers, are all real facets involved with curing this but I do request that you look at these patients disease. as having a disease that can be cured and to That being said I implore the readers of look at yourself as having the skills to be a part this article to not give up. When your patient of the solution. presents and you suspect addiction, be forth-

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the DateS

January 25-28, 2018 May 2-5, 2018 August 3-5, 2018 POMA District VIII POMA 110th Annual POFPS 43rd Annual 31st Annual Clinical Assembly & CME Symposium Winter Seminar Scientific Seminar Hershey Lodge Nemacolin Woodlands Radisson Valley Forge Hershey, Pa. Farmington, Pa. King of Prussia, Pa. 20 1A AOA CME credits 20 1A AOA CME credits 34 1A AOA CME credits — seminar details will be — seminar details will be — seminar details will be available in May 2018 — available in October 2017 — available in December 2017 —

14 / September 2017 The Journal of the POMA CME Quiz

Name To apply for CME credit, POMPAC answer the following questions and return the AOA # completed page to the IS POMA Central Office, 1330 1. The number of deaths from prescription Eisenhower Boulevard, opioids has generally stabilized since 2011. Harrisburg, PA 17111-2395. True False Upon receipt of the quiz, we will forward passing scores to the AOA CME 2. The majority of people who misuse Department. You will receive The Collective Voice prescription opioids get them from their 0.5 Category 2B AOA CME of the physician(s). credits. True False Osteopathic Profession Answers to 3. Overdose is the number one accidental Last Issue’s killer in Pennsylvania. CME Quiz True False 1. True 4. In the past two years, Pennsylvanians 2. b used medication drop boxes to dispose of how 3. b much old, unwanted medications: 4. c a. over 1 ton 5. d b. over 25 tons c. over 50 tons (Questions appeared in the June 2017 d. over 75 tons Journal.) e. over 100 tons

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