Nicotine & Vaping WYNTK

I’m a longtime friend of the Hazelden Betty Ford Foundation and have frequently collaborated with Hazelden Publishing on various educational offerings. What You Need to Know (WYNTK) is the latest series

We filmed the Nicotine & Vaping program in late February, which seems like years ago because of Covid-19. It’s now available for preview and purchase

Hazelden Publishing

Many thanks to Wes Thomsen and his crew at Hazelden Publishing for involving me in this project. My previous appearances can be found here and here. ✸

Coronavirus Response

Our response to the novel coronavirus is based on recommendations from the Centers for Disease Control and Prevention and Minnesota Department of Health. Our primary strategies are:

A virtual visit is an online appointment that supports social distancing, that is, unnecessary, in-person contact with others. These visits occur via Zoom for Healthcare, a secure, HIPAA-compliant platform.

Please consider converting your existing in-office appointments to virtual visits. ✸

Nicotine & Vaping WYNTK

I was in medical school when the Tobacco Master Settlement Agreement occurred. It was a major public health victory that was quickly eclipsed by the opioid epidemic.

But nicotine never really went away. If anything, it metastasized into more insidious social problems.

Teens have been trading traditional combustible cigarettes for “vaping.” Use of cigarettes and smokeless tobacco declined between 2011 and 2015. This was basically offset by a sharp increase in the use of e-cigarettes (1.5% to 16%) and hookahs (4.1% to 7.2%). The net net was no change in overall tobacco use (24.2% vs. 25.3%).

Severe vaping-related lung injury is just the latest wrinkle.

Top Right: Wes Thomsen (red shirt), Brad Hadsall (far camera) and Sylvia Juarez (near camera).

With this context in mind, I was in studio yesterday to shoot the third installment of Hazelden’s What You Need to Know series. Opioids and Meth packages are already available for purchase. Nicotine & Vaping, Alcohol and Cannabis packages can be preordered.

Many thanks to Wes Thomsen and his crew at Hazelden Publishing for involving me in this project. My previous appearances can be found here and here. ✸

Telehealth Suboxone

Methadone, the first evidence-based treatment for opioid addiction, appeared way back in 1965. In the years that followed, “methadone clinics” popped up in large cities that could financially support them. But most patients—especially those in greater Minnesota—were unable to access this potentially life-saving care.

The U.S. Food & Drug Administration attempted to remedy this health disparity by approving Suboxone in October 2002. The hope was that family physicians, internists and psychiatrists would prescribe it in their clinics, thereby creating broad access to addiction care.

Suboxone was originally available as a sublingual tablet. Source: CVS/pharmacy

Unfortunately, that idea was very slow to take off. Rural providers cited a range of barriers—time, risk, lack of ancillary mental health services—as reasons for not prescribing. As a result, Suboxone tends to be available through addiction medicine specialists (like me) who practice in large cities and are subject to federally-imposed patient limits.

About a year ago, Allina Health decided to take a different tack. We came up with a simple access strategy:

  • Addiction medicine specialists treat patients for opioid addiction via telehealth
  • Specialists transfer care to local primary care providers once patients are stable
  • Primary care providers can always consult with addiction medicine specialists or return patients to us if there are struggles
My telehealth studio (left). Laura Moldan, a nurse at New Ulm Medical Center, posing as a patient (top right). Provider interface (bottom right). Epic, the electronic health record, is running on the larger screen. Vidyo, the HIPAA-compliant audiovisual application, is active on the smaller screen. No protected health information (PHI) appears on the screens

The first provision addresses primary care providers’ concerns about treating active substance abusers. The second feature ensures that addiction medicine specialists always have capacity for new patients. The last design feature is how primary care interacts with every other medical specialty—cardiology, nephrology, endocrinology—when it comes to chronic disease management.

And it worked!

Our pilot program at New Ulm Medical Center, a critical access hospital, was a resounding success. We’re presently working to scale it to Allina’s entire service area. We’re also launching virtual visits next week, which will allow patients to be seen via their own smartphone or tablet.

All of this was a heavy lift by a committed team:

The view from my office on the 14th floor of the Medical Arts Building in downtown Minneapolis

The addiction medicine specialists are still located in a large city many hours from patients but distance is no longer a barrier to receiving care. ✸

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Postscript. I received a good question about the Ryan Haight Act. Our program is exempt from the in-person medical evaluation requirement as New Ulm Medical Center is a DEA-registered hospital. Please consult your compliance department or personal attorney about your particular clinical circumstances.

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Postscript. We launched virtual visits today (February 24th) as planned. The first patient lives near the Iowa border, two hours from both New Ulm Medical Center and the Twin Cities. The virtual visit saved him roughly four hours of driving for a 30 minute visit.

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

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! §