Pain & Addiction: Common Threads

On November 1st, I’ll be presenting on the messy intersection between opioid addiction, chronic pain syndromes and other mental disorders. Please click here or on the image below for a full-sized PDF of the conference announcement.

You can register for the event here.

I’m still messing with my slides, however, my presentation will be a “new and (very much) improved” version of material that I’ve delivered to other audiences (for example, here and here)

Many thanks to Taylor Gilard, Susan Gordon, the University of Minnesota’s School of Nursing and Allina Health for involving me in the event.

Think Like a Health Plan

In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.

I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.

This post contains my key teaching points and didactic materials.

Suggested Thought Process

  1. Is the health care service a covered benefit? (cf. benefit plan)
  2. Does the carrier have a policy concerning the health care service?
  3. In the absence of a specific policy, is the health care service medically necessary?
  4. Does the member (patient) and/or evidence meet criteria?

Benefit Plan

At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).

Medical Policies

Medical Necessity

Group Exercise

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Opioid Investigations & Enforcement

I’m honored to be serving as a panelist at Fredrikson & Byron’s upcoming “Opioid Investigations and Enforcements Breakfast Seminar” on May 22nd.

Opioids are a common and sometimes uncomfortable area where law and medicine intersect. For years, I’ve been extolling the virtues of the Federation of State Medical Boards’Model Policy” as a means for mitigating risk. It also serves as an excellent framework for approaching opioid-related incidents and investigations.

Fredrikson & Byron is hosting an opioid-related event

The Model Policy first appeared in 1998 and is now in its fourth edition (2017). Section 3 provides detailed guidance on patient selection, informed consent, medication agreements, drug testing, and so forth.

Adhering to the Model Policy ensures patient safety but also provides a safe harbor against enforcement actions. For example, the Minnesota Board of Medical Practice typically includes this condition in opioid-related discipline:

Respondent shall read the Federation of State Medical Boards’ “Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain”

Adhering to the Model Policy is a good way to avoid being investigated. And acknowledging the Model Policy and demonstrating compliance with it are an effective means to respond to questions about care.

Many thanks to Kevin Riach and Joe Dixon, shareholders at Fredrikson & Byron, for including me in this event. And I hope to see you there!

Demystifying Suboxone

Suboxone was approved by the FDA way back in October 2002. Nearly 17 years on, there’s finally growing interest in its use. Primary care providers are prescribing it. And some emergency medicine physicians. Hospital medicine seems to be the next frontier.

I’m pleased to be partnering with Allina Health’s hospitalists on education and order set creation. The latter includes a presentation at their annual CME conference, offered on a repeating basis on April 5th, April 10th, April 26th and May 2nd.

Hospitalists frequently care for patients following overdoses and other opioid-related misadventures—trauma, endocarditis, and so on. Buprenorphine is a very nifty widget in these circumstances.

Another common scenario is acute pain management for patients who take buprenorphine in the community. Pain control is neither hard nor complicated, so long as you follow a few simple rules.

Special thanks to Drs. Saul Singh and David Beddow for their partnership on this.

Additional Resources
Suboxone Dosing Guide [pocket reference]
Buprenorphine Therapy for Opioid Use Disorder [journal article]
Use of Medications in the Treatment of Addiction Involving Opioid Use  [pocket reference]
Buprenorphine: How to Use It Right [journal article]

Suboxone Treatment in Jail

The Saint Cloud Times recently featured CentraCare Health’s correctional care (“jail medicine”) program. This unique public-private partnership is designed to identify and treat mental illness and addiction while inmates are in custody. We then link them to a special clinic following release to the community for ongoing management. (I serve as the medical director for the program.)

Captain Mark Maslonkowski. Photo: Jason Wachter

We launched in the Benton County Jail on October 1st, 2017, and in the Stearns County Jail on January 1st, 2o18. As outlined in the article, the early signals are promising: fewer ambulance trips between the jail and hospital, fewer detox admissions and decreased total cost of care.

As far as we know, we’re the only Minnesota counties starting inmates on Suboxone, the medication to treat opioid addiction, while in custody. And, one needs to look far and wide to find other examples nationally.

Our ever-growing provider team includes:

Providers see inmates in jail and following release to the community. This continuity of care is unprecedented. Health authorities (a statutory term) have historically focused on inmates’ immediate medical needs in jail without regard for the bigger picture. This penny-wise but pound-foolish approach doesn’t resolve some big reasons—mental illness and addiction— for criminal recidivism. Thus the revolving door.

Special thanks to my partners in crime (sorry! couldn’t stop myself):

  • Captain Susan Johnson (Benton)
  • Katy Kirchner, director
  • Captain Mark Maslonkowski (Stearns)
  • Kenzie Moehle, supervisor
  • Heather Qunell, manager

Time Machine — Clinic Grand Opening

Two years ago today, North Memorial Health opened its Mental Health & Addiction Center. Previously, it didn’t have an outpatient clinic for medication management and psychotherapy, or to receive patients following hospital discharge.

Kelly Macken-Marble and I served as the project’s executive sponsors. In truth, John Sutherland, Jackie Dean, David Oliver and Marrion Muia did all of the work. And, boy, was it a lot of work! The project involved everything from architectural drawings to clinical workflows—literally thousands of hours, decisions and details.

KSTP’s Ken Barlow, who has bravely and very publicly shared his brush with bipolar disorder, was the master of ceremony. A good time was had by all.

Middle Left: John Sutherland and Jackie Dean cutting the ribbon. Middle Right: Ken Barlow. Bottom Left: Ken Barlow; David Frenz; and Brian Johns, M.D.

Jail Medicine

This week, we paused from life’s bustle to celebrate a remarkable public-private partnership. CentraCare Health, based in St. Cloud, Minn., began discussing correctional health care (“jail medicine”) with its host counties about three years ago. This ultimately resulted in CentraCare being named as the health authority (a statutory term) for the Benton County Jail and Stearns County Jail.

I’m fortunate to be part of the team that spun up the program. Originally, it was just Katy Kirchner, Heather Qunell, Cindy Henze and me squatting in a vacant office. There were only two desks, so I typically sat on the floor with my laptop.

The program and team quickly grew to include infirmaries in the jails and a clinic to serve inmates following release to the community. Our providers—all stellar people and clinicians—are Zach DorholtBri Eriksson, Lori Korte, Julie Moriak and Cat Standfuss.

The program also owes its success to incredible nurses and support staff, and unwavering executive support. On the CentraCare side, Kelly Macken-Marble and Kathy Parsons have championed the partnership. And from the counties, Captains Susan Johnson (Benton) and Mark Maslonkowski (Stearns), the jail administrators, have been fantastic colleagues.

Many thanks to CentraCare for involving me in this deeply rewarding opportunity! §

Sunday Sermon

Well, not exactly. They didn’t let me get anywhere near the pulpit!

I did, however, speak at Gustavus Adolphus Lutheran Church for its weekly Table Talk series (the title is a nod to Luther). Last week, I presented on addiction. Today, I held forth on Rational Emotive Behavior Therapy (REBT), which is a way to reduce emotional disturbances by thinking more clearly.

My “text” for last week was Romans 7:15. I also wandered through DSM-5 and Doug Sellman’s “Top 10” on my way to Gerald May’s brilliant conceptualization. I didn’t have a text today, however, “renew your mind” would have been apt.

Many thanks to Dr. Arland Hultgren  (see, also, Amazon) for inviting me to visit such a wonderful parish. And also Rev. Tim Nelson for connecting us.

P.S. I’m a PK (pastor’s kid) and so far have avoided seminary myself. But I wound up in the “belief business” anyway. §

Inhalant Abuse

Today, I appeared in a KARE 11 story on “huffing.” Inhalant abuse is a common but largely unrecognized problem that is particularly prevalent in older children and adolescents.



Many thanks to Joe Clubb, John Sutherland and Tim Burke at Allina Health for putting this important issue on the proverbial radar. §

Understood

I didn’t know Dr. Margaret Keenan but wished that I had. One of her eulogies said this of her:

I think that what her patients craved was not to be healed but to be understood

I pray that my own demise is far off—our kids are still young and I’m just beginning to master my craft. But when I’m gone, I hope that my patients will generally recall that I understood them. §