Medicine Fall 2016 | Volume 15, Number 3

Nebraska’s Prescription Drug Monitoring Program

Physician participation a key to success

PERMIT NO. 27 NO. PERMIT

LINCOLN, NE LINCOLN,

PAID

US POSTAGE US 233 South 13th Street

PRSRT STD PRSRT Ste. 1200 Lincoln, NE 68508 Medicine is published quarterly by the Medicine Fall 2016 | Volume 15, Number 3 233 South 13th Street, Ste. 1200 Lincoln, NE 68508 Phone (402) 474-4472 President’s Message ...... 3 Fax (402) 474-2198 Executive Vice President’s Message ...... 4 www.nebmed.org 2016 Annual Membership Meeting Recap ...... 5 Nebraska Medical Association 2016-2017 Board of Directors 2016 House of Delegates Resolutions ...... 7 President Todd Pankratz, MD, Hastings NEBRASKA’S PRESCRIPTION DRUG President-Elect MONITORING PROGRAM Rob Rhodes, MD, Lincoln LB 471, Battling the Opioid Epidemic ...... 9 Secretary-Treasurer Jason Kruger, MD, Lincoln Nebraska Opioid Prevention Efforts ...... 10 Immediate Past President Harris Frankel, MD, Omaha PDMP - A Piece of the Prescribing Puzzle ...... 11 Board Members Andrea Bollom, Omaha An Emergency Room Perspective on the PDMP ..... 12 Kim Coleman, MD, Lincoln Prescription Drug Monitoring – Robert Dunlay, Jr., MD, Omaha An Important Tool in the Opioid Epidemic ...... 13 C. Jose Friesen, MD, Grand Island Jim Gigantelli, MD, Omaha Pain on the Prairie ...... 14 Shweta Goswami, Omaha David Ingvoldstad, MD, Omaha The Pharmacy Perspective ...... 15 Logan Jones, Omaha Our Duty to Meet the Future ...... 16 Gerald Luckey, MD, David City Kris McVea, MD, Omaha Kevin Nohner, MD, Omaha New Members ...... 19 Chuck Reese, MD, Lincoln Necrology ...... 19 Michelle Sell, MD, Central City Alicia Smith, Omaha Ask a Lawyer – Can a Physician be liable in a Medical Leah Svingen, Omaha Malpractice Action because of a Patient’s Suicide? .. 20 Tod Voss, MD, Pierce Michelle Walsh, MD, Lincoln COPIC – CDC Guidance on Opioid Prescribing ..... 21 Jordan Warchol, MD, Omaha Foster Group – What to Do With Your Extra Dollars .. 22 Ex-Officio Board Member KC Williams, Lincoln

The Nebraska Medical Association in no way endorses any opinions or statements in this publication except those accurately reflecting official association actions.

Page 2 | Fall 2016

President’s Message by Todd Pankratz, MD students. In the last two years we have We have a long history in the NMA President increased our endowment for student Nebraska Unicameral of supporting scholarships by $250,000. The total in patient safety and physician issues. t’s a privilege to take on the role endowed funds for student scholarships Last year we reviewed 250 bills, I of leading Nebraska physicians for is $1.5 million which may seem sufficient monitored 100 bills and were the next year. I want to thank Harris before you consider that our students actively involved in the efforts Frankel, MD, 2015-16 president, for his have an average debt of nearly $250,000 of 12 of these bills, sending dedication and leadership this past year. when they finish medical school. either letters or testifying in the Partnerships are key to making Please consider the Nebraska Medical best interest of our patients and the Nebraska Medical Association a great Foundation when determining your physicians. It is critical that we organization, and partnerships will be annual charitable donations and in continue building relationships even more important in the near future your estate planning. with our legislators. I am asking for your with the changes on the horizon for Our Foundation also provided help in this effort. We need physicians physicians in Nebraska and nationally. $250,000 for additional grants to developing these relationships and These changes include physician payment improve the health of Nebraskans. partnerships with their senators because models, employed vs. private practice We have partnered with the Nebraska they trust their personal physicians to do employment models, Enhance Health Perinatal Quality Improvement what’s right for the patients of Nebraska. Network and CHI, and lastly, the role of Collaborative (NPQIC) to improve We have some serious issues this year and specialty care in these perinatal care in Nebraska. Along including medical marijuana, opioid new payment models. As a result, it is with the March of Dimes, NPQIC drug use and reimbursement issues. imperative that we continue to create implemented a policy to ensure no When called upon we need you to write and nurture relationships that are built elective inductions before 39 weeks. a letter, make a phone call or consider on trust and not divide into different We have also given funds for simulation testifying. groups. This will forge common goals, vans to help Nebraska physicians, Finally, the NMA leadership has mutually beneficial to each individual , nurses and other care team been meeting with the leadership of and organization. We need to work members to prepare for emergencies. specialty organizations twice each year. together to make the transition into the We have also been funders for several This has been helpful in understanding new practice models successful not only other projects including the Heroes their issues and how we can assist them. for the practice, but most importantly for Program through Children’s This provides additional opportunities our patients. and NMA member Karla Lester, MD, for dialogue, understanding and uniting The NMA has a long history of which focuses to reduce childhood together on issues. creating these partnerships. In 1976, obesity. In addition, NMA member In closing, I would ask each of you we worked to create the Nebraska Bob Rauner, MD, is leading an effort to make a commitment to being part Hospital Medical Liability Act which on a statewide Nebraska physician cancer of one of these partnership opportunities. today is one of the best malpractice caps screening program that aims to identify We have a wealth of bright people in the country. Our Foundation has early breast and colon cancer with a who can affect positive change quickly partnered with our medical schools to goal of earlier diagnoses and better when mobilized. I look forward to a create scholarships for deserving medical treatment. great year. l Page 3 Nebraska Medicine | Fall 2016 Executive Vice President’s Message

by Dale Mahlman always a gift to be joined by these long- of the Nebraska Medical Association. NMA Executive Vice President time NMA members. We also presented Dues statements are a necessary part our 2016 NMA awards. This issue of in any professional association, and we nnual Session 2016 is in the Nebraska Medicine will highlight our hope to have your continued support in Abooks and was a great success. outstanding award winners; find more 2017. The NMA team is dedicated to Many thanks to those physicians and information on page 6. educating, serving and advocating for our sponsors who took the time Our meeting also provided more customers in the promotion of organized to attend this event and to insight into Nebraska’s new Prescription medicine. our great team at the NMA Drug Monitoring Program (PDMP), Next year will provide us with a for putting together another the result of LB 471, introduced in fresh start in the White House, at least outstanding event. It was no 2015 by Senator Sara Howard of 17 new state senators in the Legislature small task I might add, and Omaha. This program, which will and hopefully your continued financial they are true professionals. begin January 1, 2017, was years in the support. Our new president, Todd This year our programming making and was a group effort between Pankratz, MD, of Hastings, highlighted focused on issues pertinent to Senator Howard and her staff, along our efforts and the importance of physicians and patients alike including with the NMA, Nebraska Pharmacists continuing to partner with other physician burnout, medical marijuana, Association and other interested parties. likeminded professional associations and physician leadership, opioid abuse We want to thank Senator Howard for advocates. We look forward and management, Maintenance of her leadership on this important public to opportunities in 2017 to Advocate Certification and our concluding health legislation, an issue the NMA for Physicians and the Health of all presentation, a fascinating look at current has been actively involved with for the Nebraskans and would love to call on you drug trends within the state. What an eye past eight years. We have appreciated as one of our active members. opening presentation to end the day! the support from NeHII, the Nebraska If you need more information on As with years past, we recognized Health Information Initiative, through the NMA and our accomplishments our Nebraska Medical Foundation the legislative and development process in 2016, just give me a call. Or, visit scholarship winners rewarding Creighton as well. Their expertise and project our website and check us out on social and UNMC students who have management of this effort will go a long media. The year 2016 has been a great demonstrated both excellent academic way in making the PDMP a success. year for the NMA, and we look forward and community involvement. We also Like years past, fall in Nebraska to making 2017 even better. We’re asking had five 50 year practitioners attend. It is means football, volleyball and support for your support! l

Page 4 Nebraska Medicine | Fall 2016 2016 Annual Membership Meeting Recap Todd Pankratz, MD, installed as president of the Nebraska Medical Association

odd Pankratz, MD, of Hastings 2005-2011, he served Twas installed as 2016-17 president as Greater Nebraska of the association at its annual membership Medical Coalition meeting and House of Delegates on president and served September 16. The event was held at the as treasurer from 2011 Harris Frankel, MD, installs Todd Pankratz, MD, as 2016- Holiday Inn Downtown in Lincoln. until his appointment to 17 president of the NMA. Dr. Pankratz began his obstetric and president-elect in 2015. Dr. Pankratz has Physicians Section. He was also an AMA gynecologic practice in Hastings in 1998. served on numerous NMA committees representative to the CAPIR Council for He is certified by the American Board of and commissions including: the NMA the American Dental Association from Obstetrics and Gynecology and is a Fellow Board of Directors, the Maternal and 2011 to 2014. of the American College of Obstetricians Child Health Committee, the Medical Dr. Pankratz practices at Obstetricians and Gynecologists. Dr. Pankratz was born Home Committee, the Nebraska and Gynecologists, P.C., in Hastings. He is in Henderson, Nebraska, and completed Medical Political Action Committee, the a medical staff member of Mary Lanning his primary education there. He attended Nebraska Medical Insurance Services, Memorial Hospital where he has served Hastings College and received his Bachelor the Health Care Reform Task Force, on numerous committees. He also serves of Arts degree in 1988. After receiving the Commission on Legislation and as medical director of Hastings Family his doctor of medicine degree from Governmental Affairs, and the Nebraska Planning. His community involvement the University of Nebraska College of Medical (NMA) Foundation. He has includes serving as a charter board member Medicine in Omaha in 1992, he served served as a delegate from 2002 to present. with 5 Points Bank of Hastings, Early his residency training at Truman Medical Nationally, Dr. Pankratz is a diplomate Head Start, Rotary, Leadership Hastings, Center/St. Luke’s Hospital in Kansas City, of the American College of Obstetricians the Hastings Symphony, mentoring pre- Missouri. Following completion of his and Gynecologists currently serving as med students at Hastings College, and residency training in 1996, Dr. Pankratz the District VI chair of Nebraska. He has First Presbyterian Church. was in private practice in Iowa City, Iowa, been a member of the American Medical Dr. Pankratz and his wife, Jessica prior to returning to Hastings. Association (AMA) since 1996 where he Meeske, a pediatric dental specialist, Dr. Pankratz has been an active has served as an alternate delegate and have two children, Robert, 21, and member of the NMA since 1998. From delegate to the House of Delegate’s Young Sophia, 18. l

Thank you to our outgoing board members The NMA would like to welcome our for their service to the Nebraska Medical new board members. Association and the patients of Nebraska.

Rob Rhodes, MD Kim Coleman, MD Kris McVea, MD Chuck Reese, MD Richard Blatny, Sr., MD Jane Bailey, MD Britt Thedinger, MD Lincoln Lincoln Omaha Lincoln Fairbury Omaha Omaha President- Elect 2014-15 President Page 5 Nebraska Medicine | Fall 2016

2016 Annual Membership Meeting Recap (continued)

DISTINGUISHED PHYSICIAN 2016 2016 SERVICE TO MEDICINE OF THE YEAR 50 YEAR SCHOLARSHIP PRACTITIONERS WINNERS Patrick Clare, MD Daniel Agraz

Edward Cohn, MD Andrea Bollom Paul Collicott, MD Bianca Christensen

Calvin Cutright, MD Emory Dye John Donaldson, MD Shweta Goswami Peter Whitted, JD, MD Chelsea Chesen, MD David Dyke, MD Brett Grieb Omaha Omaha Joseph Ellison, MD Clara Hageman YOUNG PHYSICIAN PHYSICIAN ADVOCATE OF THE YEAR OF THE YEAR Albert Frank, MD Nejmun Hussain Bert Frichot, III, MD R. Logan Jones Eva Garciano Brion, MD Michaela Klesitz Martin Goldman, MD Michael Klinginsmith Philip Hofschire, MD Joseph Lippert

Duane Koenig, MD Brent Luedders Rajesh Kumar, MBBS Sydney Marsh Jiri Lukas, MD Rebecca Osborn Travis Teetor, MD Bob Rauner, MD Omaha Lincoln Joseph Lynch, MD Michelle Polich RESIDENT ADVOCATE STUDENT ADVOCATE James Manion, MD Matthew Purbaugh OF THE YEAR OF THE YEAR Pradip Mistry, MBBS John Riley Dennis O’Leary, MD Steven Shaw Eugene Peck, Jr., MD Diliana Stoimenova Gayle Peterson, MD Leah Svingen

John Reilly, MD Charles Viers Sanat Roy, MBBS Gabrielle Welch Mark Sorensen, MD Jordan Warchol, MD Michael Visenio Paul Steffes, MD Omaha Omaha Samuel Watson, MD FRIEND OF MEDICINE Larry Wood, MD

SAVE THE DATE

2017 Annual Membership Meeting Friday, September 8, 2017 Tom Obrist Lincoln Lincoln

Page 6 Nebraska Medicine | Fall 2016 2016 House of Delegates Resolutions

he following resolutions were RESOLUTION #2 – RESOLUTION #3 – Tpresented at the 2016 House of ADDRESS THE EVER CHANGING PRICE TRANSPARENCY IN Delegates. Action taken is indicated. HEALTH CARE AND PAYMENT MEDICINE DELIVERY SYSTEMS WHEREAS, the health care system RESOLUTION #1 – THE IMPACT WHEREAS, the passage of the is entering the realm of value-based OF TRAUMATIC POLICE Affordable Care Act (ACA) in 2010 has purchasing where information on EXPOSURES ON CHILD AND changed the way health care is regulated both price and quality are needed for ADOLESCENT HEALTH and financed, and physicians to help their patients make WHEREAS, the recent events have WHEREAS, the resulting effects of informed decisions, and raised awareness of significant racial the ACA since inception have included WHEREAS, the increasing deduct- issues surrounding the policing of our focus on Quality and Value-Based Care, ibles, co-payments and out of pocket communities at all levels, and the introduction of Patient-Centered expenses for patients are resulting in WHEREAS, these interactions can and Medical Homes (PCMH), adoption by significant expense for patients, and do have unintended adverse health effects Insurance Carriers of various quality WHEREAS, one of the significant of the people involved, either directly or based evaluation tools, and numerous barriers to patients is the lack of indirectly and particularly on children CMS initiatives including ACOs, and transparency regarding the cost of and adolescents, WHEREAS, the passage of Medicare their medical care, and THEREFORE BE IT RESOLVED, Access and CHIP Reauthorization Act WHEREAS, many current contracts That the Nebraska Medical Association of 2015 (MACRA) further highlighted between third party payors and health work with community and school the Quality Payment Program (QPP) care providers do not allow sharing of leaders, as well as police officials, to and Merit-Based Incentive Payment cost of care information, and develop policies that limit the impact of System (MIPS) as well as the Advance WHEREAS, many states are traumatic police exposures on children Alternative Payment Model (APM) developing programs that promote the and adolescents, especially racial and creating opportunities and challenges for availability of pricing information, ethnic minorities. the medical practices across the state, THEREFORE BE IT RESOLVED, Following introduction by Kelly THEREFORE BE IT RESOLVED, the Nebraska Medical Association in Caverzagie, MD, and discussion, a motion the Nebraska Medical Association will cooperation with business, industry was made for an amendment to the create a committee of interested and and the Legislature will work to pass resolution as follows: informed members to review and respond legislation that would make the pricing to the rapidly changing Health Care and THEREFORE BE IT RESOLVED, of shoppable health care services available Payment Delivery environment, and That the Nebraska Medical Association to both physicians and patients. Such work with community and school BE IT FURTHER RESOLVED, legislation would develop publically leaders, as well as police officials, to the Nebraska Medical Association will accessible sites that give the citizens of develop policies that limit the impact of create access to information from various the state of Nebraska accurate, compa- traumatic police exposures on children sources nationwide on these topics for rable and understandable information and adolescents. members’ education and assistance. regarding the costs of their health care. Discussion followed. After discussion Following introduction by Michelle Sell, Following introduction by Bob Rauner, of the amendment, a motion was made, MD, and discussion of the resolution, a MD, and discussion of the resolution, a seconded and approved to accept by the motion was made, seconded and approved motion was made, seconded and approved House of Delegates. to accept by the HOD. to accept by the HOD. (continued on Page 8)

Page 7 Nebraska Medicine | Fall 2016

2016 House of Delegates Resolutions (continued)

RESOLUTION #4 – will develop prediabetes within 5 years, Department of Health and Human NEBRASKA HEALTH CARE and Services in the DPP planning process for DECISION ACT WHEREAS, Congress authorized the the State of Nebraska, and WHEREAS, there is widespread CDC to establish and lead a National Di- BE IT FURTHER RESOLVED, the support from stakeholders representing abetes Prevention Program (NDPP) based NMA participate in the implementation health care, the legal profession, social on low-cost interventions that could be of the DPP across Nebraska through workers and medical ethicists in implemented across the U.S.1, and education of physicians and health care developing a set of Transportable Medical WHEREAS, the NDPP has been teams in regard to prediabetes, associated Orders for Nebraska, and shown to effectively delay or prevent pro- risk factors, appropriate interventions, WHEREAS, a group representing gression of prediabetes to Type 2 diabetes and the identification of DPP locations the above stakeholders has developed in a significant number of patients, and across the state available for referral of proposed legislation tentatively titled the qualified patients, and WHEREAS, Nebraska is one of eight Nebraska Health Care Decision Act, and states identified as having a population at BE IT FURTHER RESOLVED, the WHEREAS, most states in the country higher risk for prediabetes and diabetes NMA collaborate with interested specialty have statewide and standardized forms for and public health grants have already societies to raise awareness of diabetes Transportable Medical Orders that address been applied to establish Diabetes prevention, develop an adequate number end-of-life decisions created after a discus- Prevention Program (DPP) lifestyle of CDC certified DPP programs, and sion with their personal physician, and change programs across Nebraska coordinate efforts to obtain adequate WHEREAS, many Nebraskans would modeled after the NDPP, and funding from Medicare/Medicaid and commercial insurance programs to ensure like a consistent and easily understandable WHEREAS, the CDC, AMA, the sustainability of the DPP programs. form for communicating their end-of-life Nebraska Department of Health and decisions to medical professionals and Human Services and other organizations Following introduction by Kevin Nohner, health care facilities, are: MD, and discussion of the resolution, a motion was made, seconded and approved to THEREFORE BE IT RESOLVED, • in the process of developing plans to accept by the HOD. that the Nebraska Medical Association in raise public awareness of prediabetes and cooperation with stakeholders from health 1) Participation in a structured lifestyle change its complications/prevention programs program with goals of education (both individu- care, the legal profession, social workers ally and in group settings within the local com- • accrediting DPP based on standards and medical ethicists, support legislation munities), loss of 5-7% of body weight, and 150 developed by the CDC to assure quality minutes of moderate activity/week based on the draft Nebraska Health Care and consistency 2) United Health Group currently covering Decisions Act. these services, Medicare will begin coverage in • working with payers to cover the cost Following introduction by Bob Rauner, 2018 for CDC certified DPP of the DPP lifestyle change programs as MD, and discussion of the resolution, a 3) 58% success rate if < 60 years old, 71% a successful, cost-effective intervention if over 60; 10 year success of 34%. Financial motion was made, seconded and approved to ROI estimated at 3:1 within the first 3 years and that will delay or decrease progression to accept by the HOD. even greater savings are obtained if diabetes is diabetes in a significant number of predia- prevented over a lifetime betics and decrease expenditures related to RESOLUTION #5 – diabetes and its complications,2,3 and NEBRASKA DIABETES Resolutions may be submitted to the PREVENTION PROGRAM WHEREAS, many health care provid- NMA Board of Directors at any time WHEREAS, an estimated 86 million ers are unaware of the existence of current throughout the year. Resolutions or inqui- adults have prediabetes, but only 10% and future DPP locations across the state, ries about resolutions should be directed to NMA Executive Vice President know of their diagnosis, and THEREFORE BE IT RESOLVED, Dale Mahlman at [email protected] WHEREAS, 15-30% of prediabetics the NMA be actively involved with the or (402) 474-4472. l Page 8 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM Nebraska Medicine | Fall 2016

LB 471, Battling the Opioid Epidemic

by Senator Sara Howard accessed at no cost to the state, prescribers Our work with the PDMP and the Nebraska Legislature, District 9 and dispensers. All parties have been fight against opioid abuse is not over. working diligently to get the program I have been working closely with the pioid addiction and abuse up and running so that providers may Nebraska Department of Ois one of the fastest rising begin accessing it as early as possible and Health and Human Services, epidemics facing the nation. So many populating the system with patient data. NeHII and providers all over Nebraskans are impacted by opioid Going one step further, beginning the state to look at elements addiction, and the Nebraska Legislature on January 1, 2018, Nebraska will that will continually improve recognizes this as a major issue in require the reporting of all prescriptions the functionality of the system. our state. dispensed in the state. This will allow I will be introducing legislation In February of 2016, we passed providers and dispensers to provide in the 2017 legislative legislation to improve Nebraska’s medication therapy management to session to implement some of these prescription drug monitoring program, patients in Nebraska. Medication improvements. We continue to consider operated by the Nebraska Health management is a key to combatting prevention, provider best practices for Information Initiative (NeHII). NeHII chronic disease and improving the opioid treatment and dispensing and is the secure, online, web-based Health overall health outcomes for Nebraskans. future funding for the system upon the Information Exchange (HIE) for the state Medication management is a multi- conclusion of federal support. of Nebraska. Under LB 471, beginning faceted process of reconciling, monitoring My goal is to make Nebraska one of January 1, 2017, all controlled substances and assessing the medications an the leading states in the nation in the dispensed in our state will be required individual takes to assure compliance fight against opioid addiction and abuse. to be reported to the Prescription Drug with a specific medication regimen, I feel from personal experience that Monitoring Program (PDMP). The while also ensuring the individual avoids no family or individual should have Nebraska Department of Health and potentially dangerous drug interactions. to endure the effects of addiction Human Services, along with NeHII, Nebraska’s PDMP is an integral part of and abuse. l has been awarded federal grants that the doctor-patient relationship and the will allow the PDMP information to be medication management process.

Page 9 Nebraska Medicine | Fall 2016 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM

Nebraska Opioid Prevention Efforts

by Amy Reynoldson, DHHS Prescription and dispensers will be educated about PDMP Legislation Drug Overdose Prevention Coordinator the enhanced PDMP system in the fall of Nebraska Legislative Bill 237 was Kevin C. Borcher, NeHII PDMP Program 2016. The system will become available passed in 2011 and established a PDMP Director on January 1, 2017. through a collaborative effort of the Rachel Houseman, NeHII Project Manager Prescribers will have the option of Department of Health and Human utilizing the enhanced PDMP system Services (DHHS) and the Nebraska he Nebraska Department for patient care and treatment purposes Health Information Initiative (NeHII). of Health and Human T January 1, 2017. Prescribers and Through this partnership the PDMP Services (DHHS) has been awarded a dispensers can register for the PDMP was created utilizing the NeHII Health Center for Disease Control through the NeHII website (www.NeHII. Information Exchange infrastructure (CDC) Prescription Drug org). without state or federal funding. Overdose Prevention for Although much of the prescription States (PDO PfS) grant to Why is it important to have a reporting was done in near-real time, the focus efforts on reducing PDMP in Nebraska? data was incomplete. In 2014, LB 1072 opioid abuse and addiction Similar to the national trend, in the repealed the prohibition of using federal by working with external past several years Nebraska has seen an funds, which allowed DHHS to seek stakeholders to implement increase in visits Amy Reynoldson federal grants. three major components. and deaths due to drug overdoses, in In 2016, Governor Ricketts signed Those components include particular due to opioid pain relievers. Nebraska Legislative Bill 471 into law enhancing and maximizing the According to Nebraska Vital Records, which reiterated that, “the primary prescription drug monitoring this trend has led to a rise from 36 purpose of the PMDP is to prevent program (PDMP), establishing deaths (age-adjusted rate (AAR) of 2.2 the misuse of controlled substances statewide pain management per 100,000) in 1999 to a peak of 149 that are prescribed, allow prescribers guidelines and creating deaths (AAR of 8.2 per 100,000) in and dispensers to monitor the care and awareness about increased 2015 (preliminary data). Of these drug treatment of patients for whom such Kevin C. Borcher access to Naloxone. overdose deaths in 2015 at least 54 prescription drug is prescribed to ensure (36%) were opioid related. Prescription Prescription Drug that such prescription drugs are used for drug abuse has risen to epidemic Monitoring Program medically appropriate purpose.” proportions across the country. Although Efforts to enhance and Per LB 471, beginning January 1, the problem is not as significant in maximize the PDMP are 2017, dispensers will report all dispensed Nebraska as in many other states, the underway. These include the controlled substances to the PDMP, and state is not immune from this problem. implementation of legislation beginning January 1, 2018, dispensers According to the Drug Enforcement that requires reporting of all will report all dispensed prescriptions to Administration (DEA), Nebraska ranks dispensed prescriptions by the PDMP. DHHS will promote the use Rachel Houseman at or near the bottom for the cumulative dispensers, development of of the PDMP system as a best practice to distribution of hydromorphone and training and educational materials for the both prescribers and dispensers. oxycodone but ranks 30th in the nation PDMP and guidance from the PDMP The PDMP system in Nebraska for hydrocodone in 2013 and 2014. For Work Group. The PDMP Work Group is unique compared to others across these reasons and others, Nebraska is consists of stakeholders from several the nation. The state’s PDMP system focusing resources on the prevention of Nebraska professional associations and is 1) incorporated with the Health prescription drug overdoses. various health/medical boards. Prescribers Information Exchange, 2) a public health (continued on Page 17)

Page 10 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM Nebraska Medicine | Fall 2016

PDMP – A Piece of the Prescribing Puzzle by Liane Donavan, MD problematic; as in the hydrocodone, the PDMP, to understand what the data Pain Medicine, Lincoln Xanax, soma triad. With utilization of indicates and - more importantly - the the PDMP, there may be a realization limitations of the data. It is vital that he prescription drug monitoring that one physician is prescribing the clinicians realize that the Tprogram is a tool that the opioid while another is prescribing the program itself will not protect physicians in the state of Nebraska have “sleep aid” or “muscle relaxant.” patients from harmful use of been requesting for a number of years. One very important advantage of the medications. Additionally, The initial drug monitoring program PDMP is the ability to provide important by itself, the PDMP will not was set up through Nebraska Health information regarding a high-risk patient prevent physicians from Information Initiative (NeHII) which by identifying those patients obtaining prescribing for patients at risk only captured a portion of the patients multiple prescriptions through multiple for harm to themselves. in the state. Additionally, patients could providers and pharmacies. The risk It is important to note that, unless elect to opt out of the reporting measure. of an adverse or catastrophic event you are the original prescriber, it may When this occurred, clinical information increases exponentially when this occurs. not be possible to know if the patient is would be lost. These concerns have been Clinicians must be aware that this can taking the medication as prescribed or addressed by a new prescription drug indicate a patient with multiple medical is taking it outside the prescribing monitoring program set for release in procedures or comorbid illnesses, but parameters. There is no provision within the state on January 1, 2017. may also potentially indicate a patient the existing software to know with preci- The PDMP is intended to assure that with an intent to deceive and hide overall sion what the directions on a prescription physicians have the most accurate data medication usage. Often, patients are one medication bottle say. For example, a possible regarding which medications step ahead of the clinician who is focused prescriber in the habit of writing “hydro- have been dispensed to a given patient on trust and compassion. It will be up codone 5/325 1-2 po q 4-6 hours” creates with a given name. By analyzing a data to the prescribing physician to make a situation that allows the patient to take set prior to prescribing, it will be possible thoughtful, and often difficult, decisions anywhere between 0 and 360 pills in for clinicians to be aware of which medi- regarding high-risk patients identified as a month and still be compliant. An cations have been prescribed, by whom, receiving medication through numerous outside provider will not be able to easily in what quantities and over what time prescribers and pharmacies. discern whether a patient is taking the frame. The PDMP is not a substitute It will remain the joint responsibility medication within the expected range for good clinical decision making by the of the prescribing clinician and the or overusing the medication. It will be physician or a substitute for advanced patient to assure that medication is important for physicians to make better and open dialogue between physician and utilized in the fashion it is prescribed. decisions and to clearly communicate patient. This dialogue should focus on This is part of the function of the opioid expectations in advance of prescribing. the difference between appropriate and agreement (not a pain contract). Within In summary, the PDMP is a step inappropriate medication usage. We must this agreement, the physician and patient forward which can become a valuable always remember that the hallmark of will set appropriate boundaries for medi- tool for Nebraska physicians. We, as substance abuse disorder development is cation use, for reporting compliant use clinicians, have finally been granted our the loss of control of medication usage. and for defining the path forward should wish for an improved system and now Patients who take certain combina- adverse usage patterns begin to develop. it is up to us to evaluate and utilize the tions of medications have been shown to As with any tool, the PDMP will only information that the PDMP provides be at increased risk for abuse. The use of be valuable if it is used correctly and con- as a component in our drive to decrease opioids in combination with benzodiaz- sistently. It will be critical for physicians prescription drug misuse and abuse. l epines or sedative hypnotics is especially to understand how to appropriately use

Page 11 Nebraska Medicine | Fall 2016 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM

An Emergency Room Perspective on the PDMP

by Jason Langenfeld, MD, FACEP community. Since 2009, deaths as a result previous opiate prescriptions. Some Immediate Past-President, Nebraska of drug poisoning have surpassed deaths providers have chosen individually to Chapter American College of Emergency from motor vehicle crashes. In 2010, abandon opiate prescribing completely Physicians there were 13,652 unintentional deaths amidst concerns for complications from opioid pain medications (82.8 and liability. or years physicians have been percent of the 16,490 unintentional In the emergency department, or chided for under treating pain. F deaths from all prescription drugs), and acute care settings, we are tasked with Pain scores have become the “fifth there was a five-fold increase in treatment treating a variety of conditions with vital sign.” Our performance admissions for prescription pain relievers limited background. Whether an urban, is measured by the polled between 2001 and 2011 (from 35,648 to suburban, or rural setting, academic or satisfaction of our patients, 180,708.) In addition to mortality and community, we struggle with the balance with a focus placed on pain toll on human lives, estimates have placed between providing the relief that our management. Those scores the cost of nonmedical use of opioid pain patients need and avoiding harm with can affect our employment or relievers at up to $72.5 billion annually. medication diversion or misuse. We also compensation. In caring for With those numbers in mind, have the distinct burden of witnessing the our patients and attempting and with recent high profile cases and effects of abuse, addiction and overdose to provide them with the highest accidental deaths, there are increasing firsthand. While electronic health records satisfaction, we have worked diligently questions concerning pain management and health information exchanges can to control pain. With the reliance on practices and the prescribing of opiate be cause for frustration, they have also opiates for pain control, more and medications. CNN and other news allowed increased access to patient more prescriptions have been written. outlets have done countless specials medical information. Unfortunately, that More potent, longer-acting opiate regarding prescription medications and access is often limited and is inconsistent pain medications have been developed the opioid epidemic in the U.S. Steven at best. Many of us have made changes and marketed. Stack, MD, FACEP, the immediate to our practice and prescribing patterns According to the Centers for Disease past-president of the AMA, wrote an to try and avoid misuse of medication, Control and Prevention, the amount open letter to physicians calling on the but we are left relying on incomplete of prescription painkillers dispensed in medical profession to “play a lead role in information. We are left to wonder how the U.S. and related deaths quadrupled the opioid epidemic that, far too often, our practices affect the patient, family, from 1999 to 2013, even though the has started from a prescription pad.” We community and the epidemic as a whole. number of Americans suffering from even received a mass mailing from the The Nebraska Chapter of American pain remained essentially unchanged. Surgeon General “asking you to pledge College of Emergency Physicians The National Institute on Drug your commitment to turn the tide on (ACEP) has long advocated for a Abuse estimated in 2012 that between the opioid crisis.” prescription drug monitoring program 26.4 million and 36 million people Some emergency departments, health in our state. Dr. James Quinn, former abuse opiates worldwide, with an systems, and even state organizations are president of Nebraska ACEP, came to estimated 2.1 million people in the developing policies and recommendations our organization with a charge nearly suffering from substance to curb the prescription of these a decade ago. He expressed frustration use disorders related to prescription medications. Some are even calling for that Nebraska was one of the few states opioid pain relievers. In addition to “opioid-free” emergency departments, without a functioning Prescription Drug opiates, benzodiazepine and sedative or withholding all opiates in the case of Monitoring Program (PDMP.) We have prescriptions are on the rise as well and chronic non-cancer pain, headache, lost continued to advocate tirelessly for a may pose a threat to our patients and the prescriptions and nearly anyone with system that would work to protect our (continued on Page 18) Page 12 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM Nebraska Medicine | Fall 2016

Prescription Drug Monitoring – An Important Tool in the Opioid Epidemic by Cynthia Paul MD, JD medical use of controlled substances, leads to a breakdown in conversation. Board Certified Psychiatrist identify and deter or prevent drug abuse Once the relationship is broken, trust The Coeur Group, founding member and diversion, or inform public health in a provider is diminished, and the President-Elect Nebraska Psychiatric Society initiatives through outlining of use and conversation has stopped, there can be abuse trends.” The largest benefit of no opportunities to help heal. Ultimately, he psychiatric field is facing one PDMPs is that they can act as a way to patients are responsible for personal of the largest medical epidemics T gather information about the constantly change but providers can offer a safe of the 21st century: prescribed opioid changing drug climate in America. It is a place to keep change conversations drug abuse. According to the most resource that may not immediately affect going. Referrals to opiate replacement recent statistics, in 2014 the lives of the day-to-day life of the drug user, but therapy like Suboxone and Methadone more than 14,000 people were claimed can affect the problems of addiction on a are important. Suboxone can be safely by prescription opioids. The good news much larger scale. prescribed in a primary care setting, with is that Prescription Drug Monitoring Frequently, primary care providers are a reasonably small amount of training Programs, or PDMPs, are a new, helpful the first place patients get a prescription and planning. weapon in the war against opioid abuse. for opioid pain medication. It is easy Accessing a PDMP could start the Currently there are 49 states with active to see how dealing with repeated calls conversation about helping patients PDMPs; the District of Colombia and for opioid prescriptions, requests for address a use disorder. After developing U.S. territory Guam join these states. increasing amounts of medications and a treatment plan with a patient, not Several studies have shown that states repeated excuses about why scripts are for a patient, the PDMP can help with PDMPs have lower rates of patients needed can take its toll on our already with accountability, and analysis of admitted into opioid treatment programs overworked primary care colleagues. whether a treatment plan is working or than states without. I encourage providers to view these needs to be changed. The PDMP can Nebraska has a rate of 79 painkiller requests through a different lens. No one also help collaborative care hopefully prescriptions per 100 people. This intends to develop an opiate use disorder. resulting in a reduction in amount of statistic isn’t necessarily indicative of an Most patients are embarrassed and opioids prescribed if warranted, and addiction epidemic, but it is significant ashamed of their use disorders. possibly lowering the risk to a patient because it shows the large amount of Requiring frank difficult of developing an opioid use disorder. opioids circulating through our state. conversations in the office prior to Substance use disorders are complicated LB 471 enhanced the state’s prescription refilling pain meds can facilitate change. and hard to treat, like many illnesses. monitoring system to better prevent Providers facilitate change when they As medical professionals, we need to be misuse of prescription drugs by requiring are empathetic and accept that patients vigilant to treat people with substance dispensers of prescriptions to report are ambivalent. Change, to most, is use disorders with same respect, patience prescriptions and also made the system uncomfortable, even if it is for the better. and compassion we strive to provide to free and accessible to all prescribers Lecturing, giving advice, and directly all patients. Empathy and compassion, and dispensers. trying to persuade patients to change are frank discussions, rolling with resistance The benefits of PDMPs extend far counterproductive. It does not resolve and open lines of communication are our beyond Nebraska. In a statement from ambivalence and encourages resistance. tools in combating opiate use disorder. the National Alliance for Model State Though conversations about substance Hopefully, the PDMP can be one more Drug Laws, a PDMP is a tool that can use disorders are difficult and at times tool in this fight. be used to: “support access to legitimate l frustrating, arguing with a patient

Page 13 Nebraska Medicine | Fall 2016 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM

Pain on the Prairie

by Mike McGahan, MD in my little hometown newspaper, just filled 90 Percocet last week; do I Emergency Medicine (see Grand Island Independent, August want them to fill the 20 Percocet that I Grand Island 21, 2016, page 3A, ‘Opiod overdose just prescribed? One night I filled Lortabs deaths on the rise, many due to for someone I thought was a legitimate atients have pain. In the prescription drugs’) patient. The next night I was working at PEmergency Department we What we have now is the law of another emergency department 90 miles manage all kinds of pain: chronic, acute, unintended consequences coming into down the road, and the same patient subacute, holding severed play. We have treated pain aggressively shows up with the same complaint and fingers, headaches, toothaches, to comply with JCAHO requirements, asking for the same prescription thinking back pains, fractures, sprains patients’ rating of their pain and I did not recognize him. and on and on and on. I give hospitals’ concern with patient survey The problem here is that we had no patients the benefit of the results (“Did we treat your pain to way of tracking controlled medications, doubt the first time I see them your satisfaction?”) The unintended i.e. opiates, until now. Starting 2017 the that their pain is real. This is consequences are overdoses, addicts and Nebraska Prescription Drug Monitoring how I have practiced especially stimulating illegal drug business. Program will come into effect. Nebraska since the Joint Commission (JCAHO) Illegal drug business; how is that is one of the few states that did not have in 1996 told us that pain is the 5th vital possible? We have the increasing number such a program. I am licensed in Kansas sign, and we should address pain as such. of addicts which is the demand side of which has such a program. The program, We should have the patients rate their the graph. The supply side is one Percocet KTRA Cs, is easy to use and only pain on a 10 point scale and address the goes for $20 - $30; at least that was the requires signing up online and changing pain. But something happened over the going price the last time I spoke with your password every three months. It also years since that time. As we implemented one of our street cops. Looking back, integrates with the surrounding states the pain scale and treated the 5th vital how am I going to sort out the legitimate that also have such programs. This is sign, the number of opiate overdose patient from the entrepreneur? Do the a tool to help us monitor patients that deaths have increased yearly. Not only math, 30 pills times $30 = $900 times are either episodic or we see in offices opiate overdose deaths increased, but 3-4 prescriptions is $2,700 – $3,600. frequently. The problem of identifying the number of opiate addicts has also Not bad for a few days of traveling from legitimate patients and making correct increased. And if you have ever tried to this emergency department to another pain treatments will be helped by such a get an opiate addict into a treatment emergency department or even to a program. Nebraska’s program will have program, good luck because they are provider’s office. The State Patrol used most of these features and will be quite few and far between. The problem falls to give us warnings about professional useful to all medical professionals, just back on law enforcement and emergency patients in the area or being reported at ask any cop or emergency medicine doc. departments; ask any cop or emergency different emergency departments. That I encourage you to sign up for and use medicine doc. This story has been all over went away with HIPPA. Sometimes the PDMP! l the news for the last several months, even pharmacies will let us now that someone

Page 14 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM Nebraska Medicine | Fall 2016

The Pharmacy Perspective by Joni Cover, JD the safe limits of controlled substance addition, some have concerns that the Chief Executive Officer across state lines. system will not be utilized by pharmacists Nebraska Pharmacists Association Nebraska pharmacists and pharmacies when dispensing and physicians when are preparing their software systems prescribing controlled s Nebraska health care providers for the interconnection to NeHII substances as has been the Aready for the implementation and the PDMP to report dispensed experience in many other and operation of a prescription controlled substances data. Because of states. drug monitoring program (PDMP), the uniqueness of pharmacy information A challenge for all health Nebraska becomes the 49th state to being reported into an electronic health care providers with the support a functioning PDMP. We record system, concerns about the ease implementation of the PDMP are, however, the first state to utilize of transmission and accuracy of the will be identifying available our health information exchange, or data once it is in the system must be resources to assist patients with addiction NeHII, to serve as the PDMP. While tested in advance. Controlled substance and substance use disorder. Nebraska’s there have been many challenges in data reporting is standard throughout health care system may not be equipped the adoption of a PDMP for the state, the industry because of the reporting or have enough capacity to provide Nebraska pharmacists have supported to PDMPs in other states. When all treatment and other necessary services the implementation of a functioning dispensed prescriptions are reported to those individuals who are in need of PDMP for the monitoring of controlled beginning in 2018, the ease of data help. Pharmacists and physicians must substance prescribing and dispensing transmission into the PDMP will be continue to communicate effectively and for years. a challenge as these requirements are in a timely manner about patients who Reaction has varied in the mandate different and unique to Nebraska. For may have addiction issues. The PDMP to report all dispensed prescription pharmacies operating in many states, will assist in identifying patients, allowing data in 2018. While some view the reporting all prescription data requires us to provide assistance that ultimately reporting of all data as a great way to changes to existing reporting processes. prevents the overuse and misuse of have access to information to assist Pharmacists are hopeful that the controlled substances. with medication reconciliation and NeHII system will allow pharmacists The take away lesson from the medication therapy management, and prescribers to sort the data in a implementation of this system is others fear that their patients may not meaningful way as to avoid information communication, collaboration and want all of their prescription data being overload. Questions from patients about interaction are all essential among all shared. Pharmacists would also like to why all of their medications are going members of the health care team. After see Nebraska’s PDMP connect to the to be included and how to get access all, the goal is to establish a PDMP that PDMPs in the surrounding states to help to the information are just a few issues provides meaningful information to health care providers treat and monitor that pharmacists and physicians may deliver great care for patients which patients that may be receiving more than face in the adoption of the PDMP. In leads to a healthier Nebraska. l

Page 15 Nebraska Medicine | Fall 2016 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM

Our Duty to Meet the Future

by Doug Peterson necessary on the heels of implementation in our power to hold additional harm Attorney General of Nebraska of a PDMP. They have learned that once from coming across our borders. needed and necessary accountability for The Summit was spent defining the he conversation in Nebraska distribution of prescription drugs occurs, problem and exploring best practices Tregarding prescription drug abusers may seek out alternatives. And for effective prevention, concerted law abuse reaches back into the Legislative many Attorneys General see heroin use is enforcement, and improved treatment. Chamber and the work done dramatically rising under their watch. You are able to access the entire over several years preparing for West Virginia, New Hampshire, archived Summit here: http://www.unmc. the passage of LB471, leading Wisconsin and Ohio are all seeing edu/cce/opioid/video. to Nebraska’s Prescription Drug significant statistical increases of abuse. The charge given at the close of Monitoring Program. Senator This abuse is not happening in the alleys the Summit was for open dialogue and Sara Howard introduced the of cities but in suburban homes, curbside ongoing feedback to continue to be legislative bill and subsequently in family cars, in aisles of convenience given. A Summit summary is being negotiated the various interests stores and in rural communities. The prepared which will provide tangible through to final passage, which Governor prevalence of cheaper, stronger heroin vision for our next meeting scheduled in Ricketts signed into law in February of available in pill form is an imported mid-November at UNMC. this year. concentration of this illicit drug. The formulation of a task force is My exposure to the destruction of Such a devastating landscape is being examined. The three-pronged abuse from prescription drugs came not easily overlooked. In fact, it led approach of prevention, law enforcement, through family and friends’ stories of me to reach out to Jeffrey Gold, MD, and treatment will continue to formulate suffering and anguish, some of which chancellor at UNMC, asking him to future defenses and responses to the I shared on the pages of this magazine join me in partnership for the work opioid crisis that threatens our nation. last year. My recognition of the scope of needing to be done in protecting our John Armstrong, MD, former abuse deepened when the Nebraska State state. He agreed without hesitation and surgeon general of Florida, conducted Patrol, DEA, and parents of stricken immediately offered to partner, as well as our closing session and began with a or deceased children spent time in our for UNMC to serve as host to Nebraska’s most fitting quote from George Will office, giving accounts of their own Opioid Summit held on October 14. which is appropriate for my use in deeply moving and tragic family histories. Also hosted by U.S. Attorney Deb closing, “The future has a way of arriving As I serve alongside other Attorneys Gilg and the Department of Health and unannounced.” General across the United States, they Human Services, the Opioid Summit Let us work together to do all in our too tell of the ravages of harm being was attended by 300 people from power in service to Nebraska families, wrought in their states, where opioid multiple disciplines. It serves as the first as they seek the good life. And may our abuse has been dramatically increasing. conversation in bringing and building united determination foster futures of They caution me of the watchfulness collaborative forces in our state to do all hope, protection and healing. l

Page 16 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM Nebraska Medicine | Fall 2016

Nebraska Opioid Prevention Efforts (continued) model, 3) a tool for improving national partners, such as the Substance efforts by working across divisions to patient safety. Abuse and Mental Health Services coordinate one message with partners Administration (SAMHSA), to provide and stakeholders. Communication has Comprehensive Approach - ongoing education and up-to-date best been disseminated to regional behavioral Opioid Prescribing Guidelines practices. Access to health care, support health partners monitoring network DHHS is committed to establishing for treatment and alternative methods capacity for access to and availability statewide evidence-based opioid to treat pain are important concepts of medication assisted treatment. prescribing guidelines. An internal to address in the pain management DHHS has also developed a website to DHHS team with representatives from education. support the PDMP efforts and provide multiple divisions is working closely DHHS expects these two efforts, information for prescribers, dispensers, with external stakeholders to develop prescribing guidelines and the enhanced and consumers in one location. The prescribing guidelines. The CDC PDMP, to work hand in hand to improve website includes 1) information on the Guideline for Prescribing Opioids for patient safety and reduce adverse drug PDMP, 2) FAQs for three audiences Chronic Pain, released March 2016, will interactions. As implementation moves (prescribers, dispensers, and consumers), be used as a model in the development forward, availability for ongoing technical 3) information for/about project of these prescribing guidelines. DHHS education for prescribers and dispensers partners, 4) resources, and 5) current will provide voluntary pain management will continue. This education will news related to opioid efforts. In the continuing education, focusing on the include how to use the PDMP system current era of health care delivery where statewide prescribing guidelines for all (supported primarily by NeHII) and consumers want to be involved in their prescribers. education related to opioid use, abuse, well-being, the PDMP is one way that DHHS supports increased uptake and treatment. DHHS is helping people to live better of best practices in pain management lives by providing adequate information and increased training on access Improving Awareness and treatment strategies related to pain to medication assisted treatment Given the complexity of the efforts and addiction. The website can be found (MAT). A key piece of this process to reduce opioid use and addiction, at: http://dhhs.ne.gov/publichealth/ is collaboration with local, state and DHHS has enhanced communication PDMP/ l

Page 17 Nebraska Medicine | Fall 2016 NEBRASKA’S PRESCRIPTION DRUG MONITORING PROGRAM

An Emergency Room Perspective on the PDMP (continued)

patients and allow all Nebraska providers lawmakers, law enforcement, health continue to come to us in pain and in to provide the best and most informed care professionals, victim advocates, need of help, and there will continue care. We have met with and worked with and families, we can look forward to to be a role for opiate and sedative members of our state Legislature and a PDMP that is useful, inclusive, and medications as we strive to provide the Nebraska Department of Health and accessible. I am excited at the prospect the best care for our patients. We need Human Services, relaying our experiences of a comprehensive program that is to educate prescribers on alternative and often sharing heartbreaking available to all prescribers, with complete treatments and have frank discussions stories we have seen in our emergency information; where inquiry is facilitated, with our patients on expectations of pain departments to make our case. though not mandated. I will now be control. We will benefit from cooperation Over the last few years, I have had the proud to describe the progress we have and national access to health and privilege of representing the emergency made and the efficacy of our new PDMP. prescribing information. physicians in our state within our It will help each of us to provide safer, The pendulum of medical care and national organization. I have been often informed care for our patients, and public opinion will continue to swing. asked to explain why our state was one to help decrease inappropriate opiate I know not if or where it may come to of the last without a functional PDMP. prescriptions. rest. Our charge, as it has always been, is Finally, the 2016 Nebraska Legislature Mixed messages persist and every to provide the best care for our patients passed LB471, introduced by Senator day we face conflicting public opinions and our communities without doing Howard, providing for a comprehensive and policies that can create unreasonable harm. With Nebraska’s new Prescription prescription drug monitoring program. expectations for pain control. There is Drug Monitoring Program, we will Thanks to the determined efforts not one solution that fits all settings, have an important tool to help meet by many Nebraskans, including patients or providers. Patients will that challenge. l

Over 290 pharmacies across Nebraska will take back leftover medications for proper disposal

The Nebraska Medication Education the Nebraska Regional Poison Center at consists of the Nebraska Pharmacists on Disposal Strategies (MEDS) coalition 1-800-222-1222 to find a participating Association, the Lincoln/Lancaster educates Nebraskans about drug disposal pharmacy near them. County Health Department, the and provides safe disposal options Since August 2012, 33,176 pounds Nebraska Department of Environmental to better safeguard the environment of medication have been collected by Quality, The Nebraska Regional Poison and protect public health. Over 290 Nebraska pharmacies for proper disposal. Center, the Nebraska Department of pharmacies across Nebraska are accepting This project is being offered to the Health and Human Services, WasteCap leftover, expired and unused medications state of Nebraska by a statewide coalition Nebraska, The Groundwater Foundation, for proper disposal. Physicians can direct of partners and with funding from the and the NMA. l patients to the Nebraska MEDS website, Nebraska Environmental Trust. www.nebraskameds.org. Or, they can call The Nebraska MEDS coalition

Page 18 Nebraska Medicine | Fall 2016

New Members Necrology

Bellevue Omaha (continued) Daniel George Bitner, MD John F. Fitzgibbons, MD Donny Suh, MD, FAAP Andrea Jones, MD Bellingham, WA Panora, IA Siva Sundeep Koppolu, MBBS 3/22/2016 7/16/2016 Crete Zachary Kwapnoski Troy Miller, DO Maurice F. Quinlan, MD Kenneth C. Stout, MD Daniel Kwon, MD Elkhorn Omaha Benkelman MacKenzie Laurila, DO 5/27/2016 7/21/2016 Ramya Chilukuri, MD Megan Lawless, MD Dali Huang, MBBS Huy Le, MD, PhD Coley Patrick O’Doherty, DO Carl Laeton Boschult, MD Fremont Kylie Liermann, DO LaVista Omaha Nagendra Natarajan, MBBS John Loftus, MD 5/29/2016 7/22/2016 Kearney Ly Luu, MD Daryl Rahy Stephenson, MD Robert Bass, MD Kyle Rupp, DO Ahmed Munir, MBBS Yankton, SD Perkins, OK Rina Musa, MD 6/16/2016 8/4/2016 Lincoln Heather Obregon, MD Jesse Dunn, MD Jack Keith Lewis, MD Robert Proulx Heaney, MD Spyridon Pagkratis, MD Omaha Omaha Missouri Valley, IA Jai Parekh, MBBS 6/20/2016 8/6/2016 Austin Saavedra, MD Thomas Perry, DO Omaha Oak Prachuapthunyachart, MD James Joseph Regan, MD Stephen Edward Budd, MD Arie Albulushi, MD Ahmad Qurie, MD Omaha Omaha Marcus Arthur, MD Ahmed Rahma, MD 6/27/2016 8/15/2016 Erin Ranum, MD Stephan Barrientos, MD Charles Morton Root, MD Milton Roger Johnson, MD Jarin Redman, MD David Berkheim, MD Baltimore, MD Scottsbluff Katherine Brown, DO Casey Sautter, MD 7/2/2016 8/29/2016 Vamsi Krishna Chilluru, MBBS Sophia Schneider Hester T. Lewis, MD Robert G. Townley, MD Dele Davies, MD Mohammad Selim, MBBS Lincoln Omaha Amaninderjeet Dhaliwal, MD Tiffany Tanner, MD 7/11/2016 9/9/2016 Morgan Dreesen, DO Meg Thacker Jill Faraci, MD Suraj Timilsina, MD Ali Fiamengo, DO Laura Vance, DO Mary Fortini, DO Keith Vrbicky, Jr. Rebecca Glasgow, DO Luke Wenzel, DO Christopher Graves, MD Brian Westerhuis, MD Elizabeth Hultgren, MD, PhD Kimberly White, MD Grant Hutchins, MD Jennifer Wright, MD Vikram Jala, MBBS Niraj Yadav, MBBS Aravdeep Jhand, MBBS Papillion Grant Jirka Adrienne Dekarske, MD

Dues statements for 2017 are in the mail. The NMA is proud to have not raised your cost of dues since 1996; support your profession and your patients for just over a dollar each day. We appreciate your continued support in 2017! If you have questions about membership, please contact us at (402) 474-4472. Page 19 Nebraska Medicine | Fall 2016 Ask a Lawyer Can a Physician be liable in a Medical Malpractice Action because of a Patient’s Suicide?

“ an a Physician be liable in a given them any indication of being no duty existed in Florida law to prevent CMedical Malpractice Action suicidal. Although the patient had told a non-inpatient’s suicide, the Florida because of a Patient’s Suicide?” was the the patient’s adult daughter that she Supreme Court noted that other types question posed in a recent Florida Supreme was crying easily, not feeling well, and of duties could apply such as the duty Court decision. Chirillo v. Granicz, __ that her stomach hurt, the daughter owed to the patient under the applicable So.3d__, 2016 WL 4493546 (Fla. 2016). encouraged the patient to call her statute, namely, to treat the patient physician. The patient’s husband thought according to the standard of care. The In October 2008, a his wife’s discomfort was primarily Florida Supreme Court did not decide patient called her physician’s physical rather than emotional. the issue of liability. Instead, the case was office and told the physician’s The patient’s husband, Mr. Granicz, remanded with instructions to proceed medical assistant that she subsequently filed a medical malpractice to trial. had stopped taking the action against the physician, his practice, Under Nebraska law, Neb.Rev.Stat. antidepressant Effexor. The and his practice group alleging that § 44-2810. Malpractice or professional physician, Dr. Chirillo, had prescribed the physician had breached a duty of negligence is defined to mean the medication for the patient in 2005. care in treating the man’s wife and that in rendering professional services, a The patient explained to the physician’s the patient’s suicide was a result of the health care provider has failed to use medical assistant that she had stopped breach. In his defense, the physician the ordinary and reasonable care, skill, taking the medication because the argued that he owed no duty to the and knowledge ordinarily possessed patient thought she was having side patient to prevent an unforeseeable and used under like circumstances by effects from it, such as not sleeping well, suicide while the patient was outside members of his profession engaged being under mental strain, crying easily of the physician’s control. Two Florida in a similar practice in his or in and having gastrointestinal problems. lower courts examined the facts and similar localities. In determining The patient said that she had not “felt came to different conclusions based upon what constitutes reasonable and right” since June or July. The medical how each court identified the issue to ordinary care, skill, and diligence on assistant provided the information to the be decided: In one case, whether a duty the part of a health care provider in a physician, and the physician subsequently to prevent a patient’s suicide existed particular community, the test shall changed the patient’s prescription to under the circumstances; in the other, be that which health care providers, Lexapro and referred the patient to a whether the physician had a duty to in the same community or in similar gastroenterologist. The patient was called exercise reasonable care in the physician’s communities and engaged in the back that day and instructed to pick-up treatment of the patient. same or similar lines of work, would samples of Lexapro and a prescription The Florida Supreme Court observed ordinarily exercise and devote to the for that medication. However, the office that a duty can arise because of a statute, benefit of their patients under like did not ask the patient to make an judicial interpretations of statutes, case circumstances. appointment with the physician. The law, and the facts of a given case. Where A medical malpractice case in patient picked-up the Lexapro samples a statutory duty applied, determining Nebraska requires a plaintiff to prove and prescription the day she called the whether a duty arose from the facts of the (1) applicable standard of care, (2) physician’s office. The next day, the a case was inapplicable. As a result, the that the defendant’s conduct deviated patient was found dead -- a suicide. lower court that based its decision on the from the standard of care, and (3) that The patient’s family was shocked statutory duty was determined to have the deviation from the standard was at her suicide because she had not taken the correct approach. Although (continued on Page 24)

Page 20 Nebraska Medicine | Fall 2016 CDC Guidance on Opioid Prescribing

By COPIC’s Patient Safety and Risk 1. Nonpharmacologic therapy and dose, and should evaluate benefits Management Department nonopioid pharmacologic therapy and harms of continued therapy with are preferred for chronic pain, and patients every three months or more rug overdoses are the No. 1 clinicians should consider opioid frequently. Dcause of accidental deaths in therapy only if benefits for pain and 8. Before the U.S., surpassing deaths by motor function outweigh risks. starting vehicle accidents. Many drug overdose 2. Before starting opioids therapy for and deaths involve prescription medications, chronic pain, clinicians should establish periodically during continuation predominantly opioids. Even greater by treatment goals, including realistic goals of opioid therapy, clinicians should orders of magnitude are those patients for pain and function, and consider how evaluate risk factors for opioid-related and their families affected by opioid opioids therapy will be discontinued. harms, such as sleep apnea, pregnancy, dependence and addiction. 3. Before starting and periodically during renal or hepatic insufficiency, patients Guidance strategies to combat this opioids therapy, clinicians should over the age of 65, mental health epidemic are now being endorsed by many discuss with patients known risks and conditions, substance use disorder and/ large public agencies, including the Centers realistic benefits of opioids therapy, and or prior overdose. Risk mitigation for Disease Control and Prevention patient and clinician responsibilities for includes offering naloxone especially (CDC). managing therapy. when there is a history of overdose, CDC GUIDANCE 4. When starting opioids therapy, clinicians history of substance use disorder, opioid Published in March 2016, the “CDC should prescribe immediate-release dosages ≥50 MME/day, or concurrent Guideline for Prescribing Opioids for opioids instead of extended-release/long- benzodiazepine use. Chronic Pain” report is directed at primary acting opioids. 9. Clinicians should review the care physicians who are prescribing 5. Clinicians should prescribe the lowest prescription drug monitoring program opioids for chronic pain outside of active effective dosage, and should carefully (PDMP) when starting opioid therapy cancer treatment, palliative care, and reassess evidence of benefits and risks and periodically, ranging from every end-of-life care. However, the report has when increasing to ≥50 morphine prescription to every three months. recommendations relevant to all prescribers milligram equivalents (MME)/day, and 10. Clinicians should use urine drug of opioids with extensive analysis of the should avoid increasing dosage to ≥90 testing (UDT) before starting opioid evidence related to: MME/day. therapy and consider UDT at least • When to initiate or continue opioids 6. Long-term opioids use often begins with annually. for chronic pain treatment of acute pain. When opioids 11. Clinicians should avoid prescribing • Opioids selection, dosage, duration are used for acute pain, clinicians should opioids and benzodiazepines follow-up and/or discontinuation prescribe the lowest effective dose of concurrently whenever possible. • Assessing risk and addressing harms of immediate-release opioids and should 12. Clinicians should offer or arrange opioids use prescribe no greater quantity than evidence-based treatment (usually COPIC suggests that all opioid needed for the expected duration of pain medication-assisted treatment with prescribers review the entirety of the severe enough to require opioids. Three buprenorphine or methadone in report, but we emphasize the following 12 days or less will often be sufficient; more combination with behavioral therapies) recommendations (note that items 6 and than seven days will rarely be needed. for opioid use disorder. 11 apply to all prescribers of opioids, even 7. Clinicians should evaluate benefits Link for the full CDC report: short-term): and harms within one to four weeks of http://goo.gl/I629u9. l starting opioids therapy or escalating

Page 21 Nebraska Medicine | Fall 2016 What to Do With Your Extra Dollars

by Marcus Iwig, CPA, CFP low, many of them are still higher than more aggressively or consider investing Provided by the Foster Group high-quality corporate and government additional dollars, depending on what bonds available to investors, and many goals exist at that point. nterest rates have been at historic investors have bonds in their investment What you do with surplus cash-flow Ilows for a number of years now and portfolio. is the right question to ask, and the best it often leads physicians to ask what they More importantly, decisions like these way to answer the question is to sit down should do with their surplus should be run through each person’s and create a long-term comprehensive cash-flow to create the most comprehensive financial plan and, like financial plan with a financial advisor wealth. Should you accelerate fingerprints, every person’s financial plan that accounts for all of your goals. If the payoff of student loans is unique. When you base the decision that’s done, then you will have a clearer and mortgage debt or should on an individual’s personal financial plan, answer for where surplus cash-flow you invest the surplus because which includes their long-term goals, should go each month to best achieve borrowed dollars are so cheap you often find this is not an either/or your goals. that, in some cases, the return decision. on the invested dollars could be higher Goals and a comprehensive plan can PLEASE NOTE LIMITATIONS: than the interest costs? work somewhat like an algorithm for Please see Important Disclosure Information and the limitations of any Looking at recent history, you deciding where to put extra cash-flow. ranking/recognitions, at www.fostergrp. could certainly make the case for Your goals will likely create a schedule com/disclosures. A copy of our current investing free cash flow over paying off for eliminating debt that may not utilize written disclosure statement as set forth on debt. For instance, the S&P 500 has all of your free cash-flow. If you want the Part 2A of Form ADV is available at annualized returns of 9.33% over the freedom to work part-time in ten years, www.adviserinfo.sec.gov. three years ending May 31, according to that may require a payment schedule for Morningstar. According to the Federal your mortgage to be eliminated by then. Foster Group Inc. is a fee-only investment Home Loan Mortgage Corporation Any free cash-flow after you’ve made the adviser firm providing a holistic approach to (Freddie Mac), the highest national monthly payment could then be invested. wealth management and financial planning, as well as traditional investment and portfolio average 30-year mortgage rate in that Likewise, if you have kids that will be management offerings. The firm has more three-year time has been 4.43% back heading to college, one consideration is than $1.4 billion in assets under management in January of 2014. That was easy, keep to determine a payment schedule that and services more than 900 clients across 39 the mortgage and invest the difference, eliminates the mortgage by the time your states, with a specialization for clients in the right? Not so fast, there’s a lot more to it first child goes to college, freeing up cash medical profession. For more information than that. We have a required disclaimer flow to help cover education costs, if please visit www.fostergrp.com/nma or call in our industry, “Past Performance Does necessary. 1-844-437-1102. Not Guarantee Future Results,” so while If you are an early-career physician The information and material provided the S&P 500 may have returned 9.33% expecting to have the opportunity to in this article is for informational purposes and is intended to be educational in . annualized over the past three years, it invest or buy into a practice in the next We recommend that individuals consult with returned -0.73% in 2015. Also, don’t few years, it may be better to direct a professional advisor familiar with their forget reducing or eliminating your extra cash to a conservative investment particular situation for advice concerning mortgage or other debt offers guaranteed so you have the capital, when needed, specific investment, accounting, tax, and legal return equal to the interest rate you pay. to buy in. Once that’s happened, you matters before taking any action. l While mortgage rates may be historically might start paying off your mortgage

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Ask a Lawyer (continued) the proximate cause of the harm to the plaintiff. Olson v. Wrenshall, 284 Neb. 445, 450 (2012). Essentially, the Florida Supreme Court in Chirillo concluded that the wrong question was being asked by one of the lower courts. The question was not whether the physician had a duty to prevent the patient’s suicide. It was instead whether the physician owed the patient a duty of care under the circumstances. In all likelihood, a similar case in Nebraska would be analyzed with reference to the “ordinary and reasonable care” standard. If faced with the same facts as Dr. Chirillo, what would you do? l Ask a Lawyer is a feature of the Nebraska Medicine. If you have a legal question of general interest, please write the Nebraska Medical Association. Answers to submitted questions are provided by the Nebraska Medical Association’s legal counsel, Cline Williams Wright Johnson & Oldfather, L.L.P., 1900 U.S. Bank Building, 233 S. 13th St., Suite 1900, Lincoln, NE 68508–2095. The answer in this issue was provided by Jill Jensen of the Cline Williams Law Firm. Questions relating to specific, detailed, and factual situations should continue to be referred to your own counsel. 4817-4587-6793, v. 1

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