SUD Case Studies: Drug Testing, Toxicology & Forensic Medicine

SUD Case studies: drug testing, toxicology & forensic medicine Dr. William Morrone, MPH Michigan State University & Shiawassee County Drug Court August 23, 2017 12-1:00PM ET

1 PCSS O Target Audience

• The overarching goal of this Toxicology and Forensic Medicine PCSS-O is to offer case-based trainings on the safe and effective use of opioid medications in pain or the treatment of opioid use disorder (MAT).

• These prescriptions should follow risk assessment based of the information found in drug testing.

• Our focus is to reach providers and/or providers-in- training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators.

2 Educational Objectives

• At the conclusion of this activity participants should be able to: § Establish evidence for the value of expanding UDS § Understand the value and limitations of UDS § Appreciate and list alternative Matrix options § Demonstrate facility in the clinical cases presented § Do not ignore old drugs like alcohol

Note: When writing your educational objectives, please reference the link below to access ACCME-approved leading verbs for formulating objectives: https://www.phscpd.org/resources/pdf/list_of_verbs_for_formulating_objectives.pdf

3 Morrone and family Disclosures

• No Relevant Financial Relationships-Commercial Interests • No Stocks • No Bonds • Medical Director: Shiawassee 35th Circuit DTCourt • Medical Director: Recovery Pathways BH Institute* • Medical Director: Holy Cross Children’s Services* • Addictionologist: 218 Fast Ice Drive, Midland MI • Associate Clinical Prof Michigan State University The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information.

4 Dr. Wm. Morrone

• Naloxone & Recovery Advocate • Toxicologist – UMKC & BCHD • Deputy Medical Director BCHD • Deputy Chief Medical Examiner BCHD • Armed Forces Institute of Pathology AFIP • Public Health – Servant – Teacher • Advocate Physician for social change • Addiction Medicine fellowship director

5 Topic: Pain Management & Addiction Topic: Addiction Medicine 6 CME credits Wednesday, March 11, 2015 - 8:30 am - 3:30 pm Genesys Conference & Banquet Center: 805 Health Park Blvd, Grand Blanc, MI COURSE DIRECTORS: William Morrone & Carl Christensen—MiSAM

8:30 a.m The Wean: Opiate Controversies and Risks 12:00 p.m Opioids for Pain in Cancer and Non- William Morrone, DO Cancer cases William Morrone, DO 9:00 a.m Patient Selection Model for Weaning off Opioids 12:30 p.m Lunch William Morrone, DO and Carl Christensen, MD Beef and Broccoli, Spicy Sesame Noodles, Stir Fried Beans, Salad 10:00 a.m Zeronarc Non-Opioid Adjuvants and Vegetarian Option Available Medical Marijuana Call to reserve - (810) 606-6527 William Morrone, DO 1:00 p.m Opioid Addicted Patient: Role of Drug 10:20 a.m Break Screening Carl Christensen, MD 10:30 a.m Benzo Risk: Opioid Combinations to Avoid Carl Christensen, MD 2:00 p.m Role of New Pain Medicines William Morrone, DO 11:30 a.m Fibromyalgia Update William Morrone, DO 3:00 p.m Case Study William Morrone, DO and Carl Christensen, MD

Goals and Objectives: By the end of the program, learners will improve their management of chronic pain by 1: knowing when and how to wean opiates 2. transitioning chronic opioids from short to long acting 3. prescribing appropriate medications for break through pain 4. utilize adjuvant medications correctly 5. understand the science behind medical marijuana 6: apply principles discussed to treat special populations of pain patients.

Handouts: Handouts will be available on-line the evening before the program. Missed something from last month? They will be on- Thankline for one more and month! acknowledge Go to: www.genesys.org - Education - Physician Education - Congdon Handout (on right)

Carl Christensen,Accreditation Statements: MD for Pre-Registration-by Friday 3/6/15: Physician: Online at www.genesys.org/CME Statement of Accreditation or by phone (810) 606-6527. Genesys Regional Medical Center (GRMC) is accredited by Practicing physicians - $85 thehis Michigan collaboration State Medical Society to provide and continuing Retired Physician and Other Health medical education for physicians. Professionals - $65

No registration required for Genesys Century 6 AMA Credit Designation Statement slide data Club Members. GRMC designates this live activity for a maximum of 6 AMA Genesys employees please register through PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the GLI. the activity. REGISTRATION - after Friday 3/6/15 and at Conference: AOA Credit Designation Statement Practicing physicians - $100 GRMC has requested that the AOA Council on Continuing Retired Physician and Other Health Medical Education approve this program for 6 credits of AOA Professionals - $75 Category 1-A CME credit. Approval is currently pending.

Nurses: In the state of Michigan, Category 1 Physician Credits are applicable to nursing CEUs.

Is the opioid crisis a pandemic?

• A pandemic is an epidemic that occurs across several countries and affects a sizable portion of the population. • There's no formal definition of "sizable." • The last CDC pandemic took place in 1968-69, when the Hong Kong flu killed 33,800 Americans. • CDC 2015: 52,404 drug O.D. overdose deaths. • 33,091 opioid O.D. deaths. 7 Number of drug poisoning deaths by category, United States, 2011-2015

2011 2012 2013 % % % 2014 Change Change Change 2015 (% Change 2012- 2011- 2011- 2013 2013 2014 2013-2014) MMWR

All drug 41,340 41,502 43,982 47,055 6.00 6.40 13.8 52,404 Total (+6.5%) deaths (+12%)

Heroin 4,397 5,925 8,257 10,574 39.40 87.80 140.48 12,990 deaths (+26.0) (+23%)

Rx 16,917 16,007 16,235 18,073 1.40 -4.00 6.83 20,101 opioid (+11.3) (+12%) deaths

Source: Modified Center for Disease Control and Prevention, (CDC Wonder) Available at http://www.cdc.gov/. All opioid deaths 33,091 and 9,000 fentanyl (>70%) 8 OPIOID PANDEMIC • Russia • Western Europe • China • Central Asian • Kazakhstan • America (US) • Costa Rica • Canada • New Zealand • Estonia • Italy > Germany • Iran

• Argentina 9 Merriam - Webster

• Definition of toxicology • Definition of forensic plural toxicologies 1 belonging to, used in, or judicature or to public discussion and debate a lawyer's forensic skills the scientific study of 2 argumentative, rhetorical forensic the adverse effects of eloquence chemical substances on 3 relating to or the living organism dealing with the application of scientific knowledge to legal problems like forensic medicine

Naltrexone extended-release injectable suspension 380 mg (Vivitrol®) for the treatment of alcohol and opiate dependence.

Naltrexone tablets 50 mg (ReVia®) for alcohol and opiate dependence

Brief discussion about alternative medications to antagonist therapy to treat addictions including:

- Partial agonist therapy with buprenorphine products buprenorphine or buprenorphine/naloxone film or tablet (Suboxone®, Suboxone Film® & Subutex®) for opiate dependence indications. - Full agonist therapy (methadone) - Other partial agonist therapies for addiction i.e. Varenicline (Chantix®)

All other discussion is off-label

UDS

UDT

Confirmant

12 Needs: UDS + confirmation = UDT

• Risk management is about protecting patients and you. • This PCSS will examine risk management in general, and urine drug testing (UDT) in particular, as core constituents in an effective, comprehensive strategy. • Today’s PCSS will explore UDT as a tool to help practitioners and patients make better choices in MAT. • How one makes these difficult clinical decisions based on UDT results as well common barriers encountered in conducting patient-centered UDT will be opined.

13 14 15 https://www.cdc.gov/drugoverdose/ data/prescribing.html

• Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014,1 but there has not been an overall change in the amount of pain Americans report.2,3 During this time period, prescription opioid overdose deaths increased similarly. • The supply of prescription opioids remains high in the U.S.4 An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings.3 From 2007 – 2012, the rate of opioid prescribing has steadily increased among specialists more likely to manage acute and chronic pain. Prescribing rates are highest among pain medicine (49%), surgery (37%), and physical medicine/rehabilitation (36%). • However, primary care providers account for about half of opioid pain relievers dispensed. • Health care providers, including those in primary care settings, report concern about opioid-related risks of addiction and overdose, as well as insufficient training in pain management. Although prescription opioids can help manage some types of pain, there is not enough evidence that opioids improve chronic pain, function, and quality of life. Moreover, long-term use of opioid pain relievers for chronic pain can be associated with abuse and overdose, particularly at higher dosages.

16 Only 8 % of primary care use urine drug toxicology

Primary care accounts for half of all

opioidsno UDT dispensed;UDT only 8% use urine drug toxicology.

17 WARNING: • DUE TO THE GRAPHIC NATURE OF FORENSIC MEDICINE & TOXICOLOGY YOU ARE WARNED THAT THERE MAY BE ANY OF THE FOLLOWING: • ORGANS • BODIES or NAKED BODIES • BODY PARTS • BODY FLUID COLLECTION

18 Common Matrix Choices in SUD

19 URINE IS A MATRIX AND THE MOST COST AFFORDABLE VENUE 20 HOW DO THESE ALL RELATE?

NIDA/NIH HHS/ CDC Executive/ SAMHSA HHS

Stop 275 LIMIT CDC pain • OBAMA & OverRx guidelines TRUMP OPIOIDs HHS PLAN

UDS YES YES YES • YES

PDMP YES YES YES • YES

Naloxone YES soft YES • YES

Treatment YES YES YES • YES

PLAN/MAT 2121 MRO screen (confirmation) cutoff

Drug Cutoff (ng/ml) cocaine 150 (100) amphetamine 500 (250) THC 50 (15) morphine 2000 (2000) 6 monoacetyl- 10 (10) morphine (6 MAM) PCP 25 (25)

22 URINE DRUG SREEN

• Protects patient & you • Normalize as routine POC testing • Recognize as an inflection point • Medicalization of conversation • Practice your narrative around it • Introduces truth in a relationship

23 Why is the UDS more important than the PDMP? • UDS TELLS YOU WHAT IS IN THE BODY. • PDMP TELLS YOU WHAT IS PRESCRIBED BY OTHER PROVIDERS. • UDS identifies diversion, illicits, alcohol or marijuana

24 PROBLEMS WITH URINE MATRIX DRUG CUP or oral SCREENS Is your medication tested by the screen? § Methadone: not routinely on 5 panel § Fentanyl: not on cups § Naltrexone: not on cups § Buprenorphine: not 5 panel; special order § Opioids vs. Opiates: need to check w/ MFG § UDS or oral may not test the METABOLITE? (Norbuprenorphine, 6-beta-naltrexol & EDDP)

25 CASE # 1

26 Pain clinic uses 5 panel (cheap) cup.

• A patient is referred to you by said local pain clinic for diversion of Fentanyl. • She had been prescribed Fentanyl patches, 50 mcg/hr, for many months. • At a follow up appointment, she tested negative and was discharged by them.

27 Pain clinic uses 5 panel (cheap) cup.

(from opium 100%) (derived from opium) (man made)

Codeine Buprenorphine Meperidine

Morphine Hydromorphone Fentanyl

Thebaine Oxycodone Propoxyphene

Oxymorphone ** Methadone

Hydrocodone

29 CASE # 2

30 Mother is in residential care and Phase II methadone clinic status • Her child presents obtunded and sleepy weekly • Mom says she is breast feeding • Methadone is kept on site in Queen of Angels (60 mg/day) • Room audit discovers INFANT Tylenol bottle, with dropper, hidden in room • Tylenol bottle has an unidentified liquid in it.

31 32 Mother is in residential care and Phase II methadone clinic status • EDDP was untested in the baby. • Methadone level in baby was 4-8 times published methadone levels in babies breast feeding with mothers that were methadone patients. • Nursing staff requested mother produce breast milk from vacuum assisted breast pumping for the lab. Mother declined.

33 Mother is in residential care and Phase II methadone clinic status • Mom was cheeking methadone • Mom was regurgitating methadone • Mom was dosing baby herself for reasons unknown

34 HEROIN – MORPHINE issues

§ Heroin: specific metabolite is 6 MAM, lasts for only a few hours; often shows as “morphine” (very high level) § Morphine only has 4 sources: § Codeine product § Morphine product § poppy seeds § heroin § Cutoff was raised from 300 ng/ml to 2000 ng/ml by SAMHSA 35 Morphine comes from poppy seed foods, codeine, morphine or heroin

36 37 CASE # 3

38 NEW patient looking to start MAT

• On your day in the methadone clinic you have to assign a risk level to a new patient • She obtains clonazepam, butalbital and oxycodone from a Neurologist for migraine headaches; she is allergic to sumatriptan • Pharmacies are refusing to fill Neurologist’s prescriptions 4 local hospitals have taken away his privileges • Is she low risk? • Is she moderate risk? • Is she high risk?

39 A patient with a new drug dealer…….

40 Overdose: Paul’s Motel 12/26

• Heroin • Amytriptyline • 6 MAM • Sertraline/Zoloft * • Morphine • Zolpidem/Ambien * • Fentanyl • Benadryl • Oxycodone • Nicotine • Clonazepam • Cotinine • THC • Benzoylcognine • Cocaine • Dextromethorphan • Methadone • Phenergan

41 Amphetamine drug cup screen issues

• May measure amphetamine, methamphetamine, MDMA (Ecstasy) • Many false positives by immunoassay • May detect amphetamines, methamphetamines, and MDMA (ecstasy) • One of the few drugs with false positive on confirmation (Vick’s Inhaler) • YOU WILL NOT PICK UP CONCERTA ® or RITALIN® (methylphenidate).

42 CASE # 4

43 Arlene Stanton, PhD HHS (2005)

44 Female starts MAT asking for help after her boyfriend self-discharged to MAT

• Male self discharged from MAT after transfer to a methadone clinic with a memo of understanding • 120 days with no UDS improvement • Missed 9 mandatory counseling sessions • Never attended group counseling • Buprenorphine present in screen cups • Norbuprenorphine not present on confirmation • Girlfriend starts after male self discharge • Second week toxicology seen in next slide

45 Female starts MAT asking for help after her boyfriend self-discharged to MAT

• Male self discharged from MAT after transfer to a methadone clinic with a memo of understanding • He had 120 days with no UDS improvement • Missed 9 mandatory counseling sessions • Never attended group counseling • Buprenorphine present in cups • Norbuprenorphine not present on confirmation • Female starts clinic after boyfriend self discharge • Second week toxicology seen in next slide

46 FEMALE ORAL 47 HER UDT on HIS UDT on WEEK #2 Discharge D/C AMPHETAMINE POSITIVE POSITIVE

METHAMPHETAMINE POSITIVE POSITIVE

BUPRENORPHINE and POSITIVE POSITIVE NORBUP

ETG + ETS POSITIVE POSITIVE

NORHYDROCODONE POSITIVE POSITIVE

THC-COOH POSITIVE POSITIVE

48 In America, Marijuana users continue to seek hydrocodone, oxycodone, lorazepam, clonazepam & alprazolam from the PCP

49 50 CASE # 5

51 TO ERR IS HUMAN

• DRUG TESTING, TOXICOLOGY and FORENSIC MEDICINE CAN BE EASILY BE IGNORED

• DRUG TESTING, TOXICOLOGY and FORENSIC MEDICINE CAN BE incompletely or erroneously translated.

53 54 The last 7 months of Elvis’ life he was prescribed ++ 8,000 pills.

Including but not limited to: • Meperidine (Demerol®) opioid • Oxycodone (Percodan®) opioid • Hydromorphone (Dilaudid®) opioid • Methaqualone (Quaalude®) hypnotic

The cause of death was heart (2)attack and (1)failure?

55 NIH Conclusions Sept 28-29 2014

Long-term opioid therapy was associated with increased risk of: • Aberrant drug-related behaviors ranged from 5.7 percent to 37.1 %. • abuse (one cohort study), • overdose (one cohort study), • fracture (two observational studies), • myocardial infarction (two observationals) • sexual dysfunction (one cross-sectional study) several studies showing a dose-dependent association.

2017 PCSS-O 56 57

CASE # 6

58 SUD can happen anywhere

• 25 year old male prescribed hydrocodone • Your partner transferred him to you • He is “Running out” of hydrocodone • Your partner never uses UDS • Your partner delivered him 25 years ago • Your partner treats the whole family • Dad has thoracic compression fracture • Mom has cervical fusion • Everybody is on opioids

59 SUD can happen anywhere

• 25 year old male prescribed hydrocodone • Unemployed and smokes 5 packs a day • Lives with girlfriend (she works 2 jobs fulltime) • He has “Legal issues” for 5 years • Currently on probation • Steel plates in skull from MVA • Steel rods in long bone fixed by screws • You see linear strip of glue on posterior neck • REMOVE SHIRT for exam

60 12

61 62 14 63 CASE # 7

64 Suicide: step off 7 story building

• Homicide ruled out. Because she was talking to her psychiatrist on the phone as she jumped. • Suicide note in text messages. • There is no blood available. • The bladder is empty. No urine. • Drug and Alcohol history is significant. • Alternative matrix is needed.

65 VITREOUS MATRIX postmortum when no blood or urine is available 66 CESAR (2015) 67 68 69 70 71 Why do we do Intervention? See DuPont et al 2008. 16 US Physician Health Programs, 1995-2001 - 904 doctors, 5 year follow-up

- 647 (80.7%) completed treatment » 79% were licensed and back to work » 11% had their licenses revoked » 3.5% retired » 3.5% died » 3.2% unknown status

During 5 years of monitoring, 81% had negative

drug/alcohol tests 72 Why do we do Toxicology screening in our SUD patients? • Testing introduces truth in the relationship • Discover drugs that you do not prescribe in our patients • Discover drugs missing that you do prescribe in our patients • Accept accountability to monitor and reduce diversion

73 FORENSIC MEDICINE is needed in criminal justice

rd Way Contact Time Builds Progress the 3 Medica(on Assisted Treatment & Engagement MAT 35th Circuit Shiawassee Drug Court Dr. William Morrone, MPH, Medical Director The Honorable Ma=hew Stewart , Pat Williams Debelak Lab, Kim Krissi 74 Shiawassee 35 th Circuit DCT

75 FORENSIC MEDICINE

• KEEPING PEOPLE OUT OF JAIL MAY MEAN UDS TESTING THREE TIMES A WEEK. ($6-11/day in clinic versus $100/day in jail)

• ANY QUESTION WILL TRIGGER ORAL/SALIVA TESTING but not good for metabolites 76 Dose is nice but we also like blood levels showing % decreased opiate use. Why?

1 4 8 16 LING et al, (1998)

• Because like all patients, drug court participants don’t take the medication: • by accident, • at wrong time or • miss on purpose.

• Injectable NALTREXONE is preferred for compliance but the future present methadone & buprenorphine which risk oral non-compliance or non-adherence. 78 BalanceCase the Vignette risks and in Webinar benefits of (Optional) medication assisted treatment (MAT)

against• Case Vignette treatment incorporated w/o in webinar medication § Present case within 1-2 slides. • Simple frank detoxification and no other treatment;§ Present 1-4 clinical questions from the case that will be answered during the webinar. • Detoxification followed by antagonist therapy; Note: There are no formatting or placement requirements • Counselingfor the clinical and/or questions peer and support answers withinwithout the webinar MAT (NA); • Referralpresentation. to short- For example,or long-term you can useresidential the Polling Question function (if using GoToWebinar) to present the treatment;questions and encourage participation, or present the • Referralquestions to an in singleOTP orfor multiple methadone slides within maintenance; the or • Treatmentpresentation. with buprenorphine/naloxone OBOT. 10

RAPID FIRE CASEs

80 NEW PATIENT CANNOT URINATE on this day. Rx:16 mg Buprenorphine Q 24 hours Confirmed pharmacy pick up of all Rx’s for the last 4 weeks.

81 RX: buprenorphine/naloxone (8mg/2mg) one film S.L. every day in AM for 7 days

82 83 HE put Buprenorphine film in the cup. FRAUD. Not taken as directed.

84 VERBAL HISTORY is IMPORTANT 85 One of these patients was discharged from the clinic. Which one?

Patient Methadone Methadone metabolites

#1. Positive Negative

#2. Negative Positive

86 Patients with negative methadone or EDDP level • A: One • B: Two

87 Patients with negative methadone or EDDP level • A: One (#1.) • B: Two

88 Methadone and EDDP the methadone metabolite need to be seen together.

89 A physician is completing his monitoring agreement with the PHP. He/She returns from a medical convention in Europe.

90 Per PHP protocol, a hair sample is done after the trip. It shows cocaine.

He/She is taken off work; they are a neurosurgeon.

91 92 A patient with cocaine on their hair sample. • A: False positive for cocaine. • B: False negative for cocaine • C: True positive for cocaine. • D: True negative for cocaine.

93 A patient with cocaine on their hair sample. • A: False positive for cocaine. • B: False negative for cocaine • C: True positive for cocaine. • D: True negative for cocaine.

94 A patient with alcohol in their urine.

• Retest for alcohol. • Do hair analysis. • Do ETG. • Do ETS. • Do ETG and ETS. SAMSHA cutoff is 1000 ng/mL

95 A patient with alcohol in their urine.

• Retest for alcohol. • Do hair analysis. • Do ETG. • Do ETS. • Do ETG and ETS.

96 A physician with a history of ETOH use disorder gives repeated dilute Urine Drug Screens. They are all negative. He denies flushing. What do you do? (pick TWO….)

97 His urines continue to be dilute. A hair test is negative. A nephrologist can find no medical problem. What do you do?

98 Dilute urines, negative hair test. • Blood testing • Saliva testing • Residential treatment • PEth test.

99 Dilute urines, negative hair test. • Blood testing • Saliva testing • Residential treatment • PEth test.

100 Phosphatidylethanoamine (PEth) test

• Blood test measures levels of phosphatidylethanolamine, an alcohol specific biomarker, in the blood. PEth is used to detect prolonged or heavy "binge" alcohol consumption. It is typically detectable for 2-3 weeks but may be detectable for longer depending on how much alcohol was consumed or for how long. PEth levels above 20 ng/ml are typically indicative of moderate to heavy ethanol consumption. PEth testing is not typically sensitive to incidental alcohol exposure such as using mouthwash or hand sanitizer. • It is important to interpret in the context of all available clinical and behavioral information. • The PEth test is not intended to screen for minimal or infrequent alcohol use.

101 •

A methadone patient has multiple complaints from other clinic patients who say that he is “using”.

He has multiple negative OPI urines. He is wheelchair bound and an observed urine cannot be accurately done. Methadone is postive UDS.

102 A. Blood testing. B. Saliva testing. C. Hair testing. D. His urines are morphine negative, do no further testing. E. Discharge him from the clinic.

103 A. Blood testing. B. Saliva testing. C. Hair testing. D. His urines are morphine negative, do no further testing. E. Discharge him from the clinic.

104 OPTIONAL ANSWER B.

A. Blood testing. B. Saliva testing. C. Hair testing. D. His urines are morphine negative, do no further testing. E. Discharge him from the clinic.

105 How many drugs is this patient using?

106 How many drugs is this patient using?

A. One B. Two C. Three D. Four E. Five

107 How many drugs is this patient using?

A. One B. Two C. Three D. Four E. Five

108 109 * Not specifically detected in ARUP assays. 110 A patient with a new drug dealer…….

111 NEW FENTANYL ON UDS

• Discharge them from the clinic. • Decrease their methadone dose. • Increase their methadone dose. • Put them on buprenorphine (Suboxone® or Zubsolv®). • transfer them to injectable naltrexone (Vivitrol®).

112 NEW FENTANYL ON UDS

113 Take away summary • Every UDS could end up in court. • Do not ignore old drugs like alcohol & cocaine or metabolites. • Screening resources for fentanyl (new) & alcohol (old) are very important. • Adjust MAT based on UDS RISK for

patients safety. 114 Educational Objectives

115 PCSS-O Colleague Support Program and Listserv

• PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management. • Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

For more information on requesting or becoming a mentor visit: www.pcss-o.org/colleague-support

• Listserv: A resource that provides an “Expert of the Month” who will answer questions about educational content that has been presented through PCSS-O project. To join email: [email protected].

116

PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse Training (SECSAT).

For more information visit: www.pcss-o.org For questions email: [email protected]

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies117 of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

THE END

118 William Morrone, DO, MS, ASAM, ACOFP and AAPM, has been Faculty of Family and Community Medicine, Michigan State University College of Osteopathic Medicine (MSUCOM), and is now Asst Director of Family Medicine at Synergy Medical Education Alliance and is a liaison in the Department of Psychiatry. He is triple board certified by the American Board of Addiction Medicine, American College of Osteopathic Family Practitioners and the American Academy of Pain Management. Dr. Morrone is a Ruth Fox faculty for the 42nd ASAM 2011 Medical-Scientific Conference Washington DC and is an active addiction educator and social advocate in pain management and has contributed numerous didactic pieces on opiates, cannabis dependence and medical marijuana to the state medical and national societies in this area. He also holds a graduate degree in toxicology and pharmacology from the University of Missouri at Kansas City, graduate school of pharmacy. Most notable to pop culture cable TV news viewers is that he has been on Nancy Grace-CNN Headline News, Court TV, CNN, FOXNews Channel and MSNBC giving medical opinions on drug addiction or death and the 6 stages of decomposition. Public service is no stranger to Dr. Morrone as he is a Deputy Medical Examiner, a Diplomat of American College of Forensic Examiners and has been a volunteer firefighter. Dr. Morrone is a Medical Director at Hospice of Michigan on Mack Avenue in Detroit, Michigan and Saginaw. Dr. Morrone is a graduate of MSU, served his internship in internal medicine in Lansing at Ingham Regional Medical Center and his residency in family medicine at the Michigan State University statewide campus site at Bay Regional Medical Center. http://www.DrMorrone.com

119 800,000 - 1,000,000 soccer fields 120