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%).
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.
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.
Laura Moldan, Claire Olson, Jamie Penkert and Mindy Eichstadt; nursing staff at New Ulm Medical Center
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.
Peder Schweigert, the general manager of Marvel Bar, will also be in studio. He’s been a bartender for 15 years and about four years ago decided to stop drinking alcohol.
I’m occasionally asked if I have a personal history of addiction. I don’t but stopped drinking by my mid-30s before sober curious was a thing (I’m currently a week short of 50, so I’ve been “dry” for at least 15 years).
Some sober curious factoids appear below.
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“Would I be happier without booze? More productive? Would I feel more confident? What would it be like to never have to face another deadline half hungover? Would I be thinner if I didn’t drink? Look younger? Would I have less sex? More sex? Would the sex be better? Would I have anything to talk about at parties? Where would the glamour go? Would people think I was boring? Exactly how boring would I/life become? … I have termed this questioning as getting Sober Curious”
One U.S. Standard Drink contains 14 grams of alcohol. Examples include a 12-ounce can of beer, 5-ounce glass of table wine and 1.5 ounces of a distilled spirit like vodka
Alcohol provides 7 calories per gram. In contrast, carbohydrates (fiber, starch, sugar) and protein provide 4 calories, and fat 9
One 12-ounce bottle of beer provides 145 calories: 98 from alcohol and the rest from carbohydrates and protein
“Hangover symptoms are not just physical; they are cognitive as well. People with hangovers show delayed reaction times and difficulties with attention, concentration, and visual-spatial perception.” Veisalgia—the medical term for hangover—can be traced back tokvies (Norwegian), the “uneasiness following debauchery.” “Hangover is common and underdiagnosed and can have serious physical, psychiatric, and occupational consequences”
Just a quick post with my updated SBIRT slide deck. I mess with it a few times per year, generally when new research or policy developments appear.
Slide 39 now contains the current screening recommendations from the United States Preventative Services Task Force (USPSTF) concerning alcohol and illicit drugs. Both are B recommendations, although the latter is still is the draft stage (but is likely to become final).
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.
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)
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.
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Suggested Thought Process
Is the health care service a covered benefit? (cf. benefit plan)
Does the carrier have a policy concerning the health care service?
In the absence of a specific policy, is the health care service medically necessary?
Does the member (patient) and/or evidence meet criteria?
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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).
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.
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!
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.
The Saint Cloud Timesrecently 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.)
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.
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):
