Podcasts about pdmp

Kiera is joined by the tooth-healer himself, Jason Dent! Jason has an extensive background in pharmacy, and shares with Kiera where his pharmaceutical experience has bled over into dentistry. This includes the difference between anti-quag and anti-platelet and which medications are probably safe, what to do to shorten the drag time in the pharmacy, how to write prescriptions most efficiently, and more. Episode resources: Subscribe to The Dental A-Team podcast Schedule a Practice Assessment Leave us a review Transcript: The Dental A Team (00:00) Hello, Dental A Team listeners. This is Kiera and today is a really awesome and unique day. It is, think the second time I've had somebody in the podcast studio with me live for a podcast and it's the one and only Jason Dent. Jason, how are you? I'm doing well. Good morning. Thanks for having me. It is crazy. I I watch Instagram real like this all the time where people are like in the podcast and they're hanging out on two chairs and couches and now look at us. We're doing it. Cheers. Cheers.   That was a mic cheer for those of you who are only listening, but yeah, Jace, how does this feel to be on the podcast? It's weird. Like I was not nervous at all talking about it. I got really nervous as soon as you hit play. So if I stumble over my words, please forgive me ahead of time. Well, Jason, I appreciate you being on the podcast because marketing had asked me to do a topic about teledentistry and I was like, oh shoot, that's like not my forte at all. so   You and I were actually chatting in the hot tub. call it Think Tank session and you and I, we have a lot of good ideas that come from that Think Tank. A lot of business. no phones. That's why. We do leave our phones out. But I was talking to Jason and this is actually a podcast we had talked about quite a while ago. Jason has a lot of information on pharmacy. And if you don't know, Jason isn't really, we were going through all of it last night. It's kind of a mock in the tub. And I think it's going to be great because I feel like this is an area, I'm working at Midwestern and   knowing about how dentists, pharmacology was surely not your favorite one. Jason actually helps a lot of dentists with their clearances. And so we were talking about it and I like it will just be a really awesome podcast for you guys to brush up on pharmacology, different things from a pharmacist's side. So Jason, welcome. Thank you. Yeah, no, we were talking about it and here's like, what should I talk about on the podcast next? I have all these different topics and she's like, what do you know? And the only real interaction I have with dentists is doing clearances for procedures. We get them all the time, which makes sense.   Lots of people are on blood thinner, I've always told Kiera, like, hey, I could talk about that. Like, that's kind of a passion of mine. I'm not a dentist. Or my name is Jason Dent. So in Hebrew, Jason means tooth. No, no, no, sorry. Nerves are getting to me. Jason means healer and Dent means tooth. So my name means tooth healer. So, here's a little set. Hold on, on, hold Can we just talk about? I brought that up before you could talk about it more. So.   My name means tooth healer but I did not become a dentist. I know you wanted me to become a dentist. did. I don't know why. I enjoy medicine. I know what you're going to get to already. The things you're going to ask me. There's been years of this. But nevertheless, that's my name. We'll get that out of the way. But you did give me a great last name. So I mean, it's OK. You're All is fair and love here. SEO's up for that. But yeah, Jason, I'm going to get you right into the show. And I'm going to be the host. And we're going to welcome to the podcast show. Jace, how are you?   Good, good, good. Good, good, good. So by getting into clearances, right? This is what you're kinda talking about with you know, before we get to clearances, I actually wanted Jason, for the listeners who don't know you, who haven't talked to you, who don't know, let's kinda just give them like, how did you go from, Kiera wanted you to be a dentist, to now Jason, you are on the podcast talking as our expert on pharmacy. fantastic. I've always really loved medicine, a ton. As a kid getting headaches and taking Excedrin, like you just feel like a miserable pile of crap.   and then you take two pills and all of a sudden you feel better. Like that's amazing, like how does that happen? Also getting ear aches as a kid, just being in so much pain and then taking some medicine and you start feeling a lot better. I always had a lot of appreciation for that. I've always been mechanically inclined. I went to, started doing my undergrad and took biology and learned about ATP synthase, which is a spinning enzyme that's inside the mitochondria, like a turbine engine. I used to work on small engines on my dirt bike and thought that is so cool. So I really got wrapped up into chemistry.   All the mechanics of chemistry really pulled me in. I'm not getting goosebumps. checking. I usually get goosebumps when I think about chemistry. But it's so cool. You think an engine's awesome, like pistons and camshafts and pressures, the cell is the same thing. It's not as loud, so it's not as cool. But it's fascinating. that's why we're like. ⁓   chemistry and really got into coagulation. So I did my residency after pharmacy school. we went to Arizona for three years. ⁓ You did and your main focus, you were never wanting to be the guy behind the counter. No, I haven't done that. Yeah. No, I love them though. I've always really want to go clinical. ⁓ But I love my retail ⁓ pharmacists. They're amazing resources. And ⁓ I use the retail pharmacist every day still to this day, but I went more the clinical route, really love the chemistry aspect of it.   did my doctorate degree and then I did my residency in Reno. Reno's kind That's how we got here everybody. Welcome to Reno. Strategically placed because I was really interested in critical medicine and where we're located we cover a huge area. So we pull in to almost clear, we go clear to Utah, clear to California, all of Northern Nevada. We get cases from all over. So we actually are kind like the first hub of care for lot of areas. So we really get an eclectic mixture of patients that come in that need-   all kinds of different cases that are coming to them. So it's what I really wanted. So I did my residency in critical care there. And then for the next 10 years, I worked in vascular medicine with my final five years being the supervisor of the clinic. Ran all the ins and outs of that. So my providers, two doctors were on our view. So when we talk about dentistry, talk about production, those kinds of things, totally get it. My doctors were the exact same way, my vascular providers. ⁓   There's some pains there, right? You wanna be seeing patients as much as possible, being able to help as many people, keeping the billing up. And had other nurse practitioners, four practitioners, a fleet of MAs, eight pharmacists. We also had that one location we had, going off the top of my head, I think we had eight locations running as well. And we took care of all the different kinds of vascular cases that came to us. Most common was blood clots, ⁓ which is just a...   which is an easier way of saying VTE. There's so many different ways to say a blood clot. Like you might hear patients say, I've had a PE or a DVT or a venous thromboembolism or a clot in my leg, right? They're all clots, but in different locations. Same with an MI, and MI can be a clot as well. ⁓ there's a lot of, everybody's kind of saying the same thing, but sometimes the nomenclature can make it sound hard, but it really is actually pretty simple.   No. And Jason, I love that you went through, you've been in like, and even in your, ⁓ when you were getting your doctorate, you were in the ER. You also worked in retail pharmacy. remember you having a little sticker on your hand. And retail pharmacy, I have a lot of respect for those guys. They have a lot of pressure on them. and then you also, ⁓ what was that test that you had to take that? I don't know. You were like studying forever for it. ⁓ board certification for, ⁓ NABP. Yeah. So I did that board certification as well.   And now you've moved out of the hospital side onto another section in your career. Now in the insurance, right? So it's really, really interesting. So now I'm on the other side reading notes and evaluating clinical appropriateness and trying to help patients with getting coverage and making those kinds of determinations. So yeah, I've really jumped all over. Really love my clinical days. I know. don't I don't I do miss them. But yeah, kind of had a good exposure to a lot of.   pharmacy a lot a lot of dentists actually with all the places that come through which Jason I really appreciate that and honestly I know you are my spouse and so it's fun to have you on but when I go into conversations like this I don't know any of this information and so finding experts and Jason I think here's me talk more about dentistry and my business than I do hear about him on pharmacy so as we were chatting about this I really realized you are a wealth of knowledge because you've been on the clinical side so you've done a lot of patient care and you've seen how   medications interact and I know you've had a few scares in your career and ⁓ you've known some physicians that have had a few scares and ⁓ you've seen plenty of patients pass away working in the ER and gosh in Arizona drownings were such a big deal. I remember when you were in the ER on your rotations I'd be like who died today? Like tell me the stories and you've really seen and now going on to the insurance side I felt like you could just be such a good wealth of knowledge because I know dentists are sometimes so   I would say like maybe just a little more anxious when it comes to medications. I know that dental students from Midwestern were like here was like four months and we had to like pass it, learn it. And Jason, you've done four years plus clinical residency, plus you've been in it. And something I really love about Nevada Medicine is they've been so collaborative with you.   like your heart, your cardiologist, they diagnose and then they send to you to treat with medicine and... Yeah, I've been really lucky being here in Reno too. The cardiology team has been amazing to work with. We started a CHF program, sorry, congestive heart failure program for patients. So we would collaborate with cardiologists. They'd see the cardiologists and then they send them to the pharmacist to really manage all the medications. So there's pillars of therapy ⁓ called guideline directed medical therapy and the pharmacist would take care of all that. So that's gonna be your...   your beta blockers, your ACEs, your ARBs, your Entresto, which would be a little bit better, spironolactone. So just making sure that all these things are dosed appropriately, really monitoring the heart, and make sure that patients are getting better. we've had real positive outcomes when the, sorry, this is totally off topic. do, talk about that study. When we looked at when patients were coming to see our pharmacists in our clinic that we started up, the patients were half as likely to be readmitted. And this was in 2018, and our pharmacists,   We're thinking about all the medications. We're usually adjusting diabetes medications too at the same time. Just kind of naturally just taking care of all the medications because we kind of got a go ahead from the providers, a collaborative practice agreement that we could make adjustments to certain medications within certain parameters. So we weren't going rogue or maverick, but we were definitely trying to optimize our medications as much as possible. And then years later, some studies came out with, I'm sure you've seen Jardins and Farseegh. not trying to, I'm not.   I don't get any kickback from them. I have no conflicts to share. But because our pharmacists were really optimizing that medication, those medications were later shown to reduce hospitalizations and heart failure, even though they're diabetes medications. Fascinating. So it wasn't really the pharmacists. It was just the pharmacists doing as much as they can with all the tools that were in front of them. And then we found out that the patients were going back to the hospital.   half as much as regular patients. So, yeah, being here, it's been so amazing to work with providers here. the providers here want help, want to help patients, don't have an ego. I mean, I just, it's awesome. I love it. I do love how much I think Jason sees me geek out about dentistry and I watching Jay's geek about his pharmacy and how much he loves helping patients. And ⁓ really that was the whole idea of, all right.   Dentistry has pharmacy as a part of it. And I know a lot of dentists are sending in clearances and I know working in a chair side, it would be like, oh no, if they're on warfarin or on their own blood clot, you guys, honestly don't even know half of what I'm talking about because this is not my jam, which is why Jason's here. But I do know that there was always like, well, we got to talk with their provider. And so having Jason come in and just kind of explain being the pharmacist that is approving or denying or saying yes or no to take them off the blood thinners in different parts, because you have seen several dental   I don't know what they're called. What is it? Clarence's? that what comes to you? don't even know. All day my mind, it's like, here is the piece of paper that gets mailed to you to the pharmacist and then you mail it back. So whatever that is. But Chase, let's talk about it because I think you can give the dentist a lot of confidence coming from a pharmacist. What you guys see on that side. When do you actually need to approve or disapprove? Let's kind of dig into that. Yeah. Well, first of all, I think I'm not a replacement for any kind of clinical judgment whatsoever. Every patient's different. But the American Diabetes Association, you   I work with diabetes a lot. American Dental Association has some really great guidelines on blood thinners and I would always reference them. I actually looked at their website today. Make sure I'm up to speed before I get back on this again. They have resources all around making decisions for blood thinners. And I think the one real important thing in putting myself in the shoes of a dentist or any kind of staff that's around a patient that's in a chair, if they say I'm on a blood thinner, right, a flag goes up. At least in my mind, that's what goes up.   Like, okay, how do we get across this bridge? And I think the important thing to really distinct right then when they say they're on a blood thinner is that is kind of a slang word for a lot of different medications, right? Like it's the overarching word that everybody pulls up saying, I'm on a blood thinner. It's like, okay, but I don't know what say. It's like, I have a car. You're like, okay, do you have a Mazda? Do you have?   Toyota, Honda, what do you have? or even worse it'd be like saying I have a vehicle, right? So when somebody says they're on a blood thinner, it opens up a whole box of possibilities of what they're Blood thinners are also, doesn't, when they're taking these types of medications that are quote unquote a blood thinner, it doesn't actually thin the blood, like adding water to the blood, if that makes sense, or like thinning paint, or like thinning out a gravy, right? It doesn't do the same thing. Blood thinners, really what they're doing is they're working on the blood, which.   which is really cool, try not to tangent on that. ⁓ When they're working on the blood, it's not thinning it per se, but it's making it so that the proteins or platelets that are in it can't stick together and make a cloth quite as easy. So whenever somebody's on a blood thinner, I usually ask, what's the name of the blood thinner that you're on? It's not bad that they use that slang, that's okay, on the same page, but it's really broken into two different classes. There's anticoagulant and antiplatelet.   And a way to kind of remember which is which, when residents would come through our clinics, the way that I teach them is a clot is like a brick wall. You know, it's not always a brick wall. Usually the blood is a liquid going through. But once they receive some kind of chemical message, it starts making a brick wall with the mortar, which is the concrete between the and the bricks, the two parts. When it's an anti-quagent, it's working on that mortar part. When it's an anti-platelet, it's working on the bricks part, right? You need both to make a strong clot or strong brick wall.   But if you can make one of them not work, obviously like if your mortar is just water, it's not working, right? You're not gonna make a strong brick wall. So that's kind of the two deviants right there. So that's what I do in my mind real quickly to find out because antiplatelets are usually, so that's gonna be like your Plavix, Ticagrelor, Brilinta. And hold on, antiplatelets are bricks? Good job, bricks. They're the bricks. And so the reason I was thinking you could remember this because I'm, antiplatelets, it's a plate and a plate is more like a brick.   And anti coagulant, I don't know why quag feels like mortar to me, like quag, like, know, it's like slushy in the blood, like it's coagulating. It's a little bit of that, like, honestly, I'm just thinking like coagulated blood is a little bit more mortar-ish. And so platelet is your plate, like a brick, and anti-quag is like.   the gilly between the bricks. Okay, okay, I got it. Yeah, so there's an exception to every rule, but when they're on that Don't worry, this is Kiera, just like very basic. You guys are way smarter listening to this, and that's why Jason's here. No, no, you helped me pass pharmacy school. When we were doing all the top 200, you helped me memorize all know what flexorill is, all right? That's a muscle relaxant. Cyclo? I don't know that part. It's a cyclo, because you guys are cycling and flexing. I don't actually know. just know it's a muscle relaxant, so that's about as far as I got. When we're looking at antitick platelets, so that's the brick part, so that's going to be your, you know,   Hecagrelor, Breitlingta, Clopidogrel is the most common one. It's the cheapest one, so probably see that one the most. Those, I mean, there's an exception to every rule, but that's generally being used after like a stent's placed in the heart. It can be used for VTE, there's some out there, but that's pretty rare. But also for some valves that are placed in the hearts, it can be used for that as well. So antiplatelet, really thinking more like a cardiac event, right? Like I said, there's always an exception to every rule, but that's kind of where my mind goes real quickly, because we're gathering information from the patient.   They're on anticoagulant. Those are like going to be the new ones that you see commercials for all the time. So Xeralto, Alequis, those are the two big ones right now. They're replacing the older one. And also we were supposed to do a disclaimer of this is current as of today because the ADA guidelines do change. this will be current as of today. And Jason, as a pharmacist, is always looking up on that. I had no clue that you are that up to speed on dental knowledge. so just throwing it out there that if you happen to catch his podcast,   a few years back that obviously check those guidelines for sure. But the new ones are the Xarelto and Eloquist. They're replacing the older ones of warfarin. Warfarin's been around for a really long time. We've seen that one. Those are anti-coagulants. So when you're looking, when a patient says that, generally they're on that medication because they've possibly had a clot in the past or they have a heart condition called atrial fibrillation. Those are kind of the two big ones. Like I said, there's always caveats to it, but that's kind of where my mind goes real quickly. And then,   as far as getting patients cleared, the American Dental Association has really good resources on their website. You can look at those and they're always refreshing that up. They even say in their own words that there's limited data around studying patients in the dental chair and with anticoagulants or anti-platelets. It's pretty limited. There's a few studies, some from 2015, some from 2018. There's one as recent as 2021, which is nice. But really, all of those studies come together and it's really more of an expert consensus.   And with that expert consensus, they have kind of simplified things for dentistry, which is really nice. ⁓ comparing that to, we have more data for like total hip replacement, total knee replacement. We have a lot of data and we know really what we should be doing around then. But going back to dentistry, we don't have as much information, so they always say use clinical judgment, but they do give some really great expert guidance on that. So if a patient's on an anticoagulant, ⁓   they generally recommend that it doesn't need to be stopped unless there's a high bleeding risk for a patient. as a provider or as a clinician in the practice, you can be looking at high bleeding risk. Some things that make an oral procedure a little bit lower risk is one, it's in the compressible site, right? Like we can actually put pressure on that site. That's the number one way to stop bleeding is adding pressure. It's not like it's in the abdominal cavity where we can't get in and can't apply pressure. So number one, that kind of reduces the bleeding risk.   is number one. Two, we can add topical hemostatic agents. Dentists would know that better than me. There's a lot of topical ways to do that. So not only pressure, but there's those things as well. And also, but there are some procedures that are a little bit more likely to bleed. And that's where you and dentists would come in hand in What's the word in APO? Oh, the APOectomy. I got it right. Good job. like, didn't you tell me last night that the ADA guideline was like what?   three or four or more teeth? great question. So you can extract one to three teeth is what their expert consensus One to three teeth without. Without really managing or stopping anticoagulation or doing anything like that. I think that's some good guidance from them. I'm gonna add a Jasonism on that though. So with warfarin, I do see why dentists would be a little bit more conservative or worried about stopping the warfarin because warfarin isn't as stable as these newer agents. Warfarin, the levels.   quote unquote levels can go really high, they can go really low. And if the warfarin levels are high, they're more likely to bleed. So I do think it makes sense to have a really recent INR. That's how we measure what the warfarin's doing. I think that makes a lot of sense, but the ADA guidelines really go into the simplification version of all these blood thinners. Generally, it's recommended to not stop them because the risk of stopping them outweighs the benefit of stopping them in almost every case. Almost every case.   ⁓ So when you're with that patient, right, they say I'm on a blood thinner, finding out which kind of blood thinner that they're on, you find out that they're on Xeralto, right? How long have you been on Xeralto for? I've been on it for years. You don't know exactly why, but if they haven't had any recent bleeding, you're only gonna remove one tooth. ⁓ You can do what's called a HasBlood score. That kind of looks at the bleeding risk that they'd have. That'd be kind of going a notch above, but in my mind, removing one tooth isn't a real serious bleeding risk. I'd love to hear from my dentist friends if they...   disagree, right, but ADA says one to three tooth removals, extractions, that's the fancy word. Extractions, yeah, for extracting teeth out. Is not really that invasive. Sure. It's not that high risk, so it's usually perfectly fine. So if a patient was on Xarelto, ⁓ no other, this is in a vacuum, right? I'm not looking at any other factors, which you should be looking at other factors. I would be perfectly fine to just remove one to two.   And when those clearances come in, because dentists do send them, talk about what happens. You guys were working in the hospital and you guys would get these clearances all the time. do. We get them so often. I mean, we get like four or five a day. We'd love to give it to our students, student pharmacists, and ask them what to do. And they would usually look up the American Dental Association guidelines and come up with something. We're like, yep, that's what we say too. In fact, we say it so many times a day that we have a smart phrase.   which just blows in the information real quickly and faxes it right back to the So it's like a copy paste real quick. So what I wanted to point out when Jason told me this is dentists like hearing this and learning this, this can actually save you guys a ton of time to be able to be more confident, to not need to send those clearances on. And we were actually talking last night about how I think this might be a CYA for dentists. like, as we were talking, I think Jason, you seeing so many other aspects of medicine, like you've literally seen patients die, you've seen other areas.   And so coming from that clinical vantage point, we were realizing that dentists, we are so blessed to live in an injury. I enjoy dentistry because possibly there's someone dying, not super high, luckily in dentistry. The only time that I have actually had a doctor have a patient pass away, and it was only when they were completely sedated and doing ⁓ some other things, but that was under the care of an anesthesiologist. And so that's really our high, high risk. And so hearing this, Jason,   That was one of the reasons I wanted him to come on is to give you doctors more confidence of do we have to always send to a pharmacist? I mean, hearing that on the pharmacy side, they're just sending these back and not to say to not see why a to not cover this because you might be questioning like, well, do I really need to? But you also were talking about some other ways of so number one, you guys are just going to copy back the 88 guidelines. So so 88 guidelines. Yeah. And I think that that gives a lot of confidence to a provider or a dentist is that you can go to the 88 guidelines and read them, right? Like you're listening to some   nasally monotone pharmacist on a podcast. Rumor has it, people love him at the hospital. were like, you're the voice, he's been told he has a good radio So for the clinic, I was the voice. Like, yeah, you've reached the vascular clinic, right? And they're like, oh my gosh, you're the voice. But sorry, you me distracted. That'll be your next career, Jace. You're going to be a radio host. OK. I would love that. I love music. But you're hearing from a nasally guy, but you can actually read the ADA guidelines. You just go right to the ADA, click on Resources, and under Resources, it has the   around anticoagulants, I think that's the best way to get a lot of confidence about it because they have dentists who are the experts making calls on these. I'm just reiterating what they say, but I think it makes a lot of sense to help providers. And the reason why my heart goes out to you as well is having the providers that used to work underneath me, they're always looking for our views, which is a fancy way of making sure that they're drilling and filling. Can I say that? Yeah, can say drilling and filling. They're being productive, right? They're being productive, right?   They're always looking to make sure if a patient's canceling, like get somebody in here. Like I need to be helping people all day long. That's how I, we keep the lights on. That's how I help as many people. And so if you have a patient coming in the chair and it has an issue, they say I'm on Xeralto. Well, you can ask real quickly, why are you on Xeralto? I had a clot 10 years ago. my gosh. Well, yeah, we're pretty good to go. Then I'm not worried. We're only removing one tooth or we're just doing a cavity or a cleaning. Something like that. Shouldn't be an issue whatsoever because there's experts in the dental. ⁓   in the dental society, the ADA guidelines that recommend three teeth or less, minimally invasive. They really recommend if it's gonna be really high bleeding risk. And clinically, that's where you would come in, ⁓ or yourself. know, apioectomy is one that's like on the fence line. I don't know where implants set. though, and like we were talking, implants aren't usually like a date of procedure. Most people aren't popping in, having tooth pain, and we're like, let's do an implant. Now sometimes that can be the case, but typically that one's gonna have   a few other pieces involved. And so that is where you can get a clearance if you want to. ⁓ But we were really looking at this of like so many dentists that I know that you've seen will just send in these clearances because they are. And I think maybe a way to help dentists have more confidence is because you know, I love routines. I love to not have to remember things. So why don't we throw it in, have the team member set it up where every quarter we just double check the ADA guidelines. Are there any updates? Are there any other things that we need to do on that? That way you can just see like   getting into the language of this, of what do I need to do? Because honestly, you guys, know pharmacy was not a big portion for it, so, recommending different parts, but I think this is such a space where you can have confidence, and there's a few other things I wanna get to, and I you- I some pearls too. Okay, go. I'm so when she get me into talking about drugs, I'm not gonna stop. So, some other things around that too is these newer blood thinners like Xarelto Eloquist, they now have reversal agents, so a lot of providers in the past were really worried about bleeding because we can't turn it off. We can turn those off. Warfarin has reversal as well, right?   So I'm looking at these patients. It's really low risk. It's in the mouth, generally speaking. Very rarely are they a high bleeding risk. Now if you're doing maxillofacial surgery, this does not apply, right? This does not apply whatsoever. you're like general dentist, you're pediatric dentist. Yeah, yeah, and it's kind of on the fly. So just trying to really help you to be able to take care of those patients on the moment, have that confidence, look at the ADA guidelines, have that in front of you. I don't think it's a bad thing to ever...   check with their provider if you need to. If you're thinking, I feel like I should just check with the provider, I would never take that away from you. But I just want to kind of steer towards those guidelines that I have to help. But what did you want to share? No, yeah, I love that. And I think there were just a few other nuggets that we were chatting about last night that can help dentists just kind of get things passed a little bit easier. So you were mentioning that if they were named to their cardiologist, what was it? was like, who is the last? Great question. Yeah, when a patient's on a blood thinner,   It could be prescribed by the cardiologist. It could be prescribed by the family provider or could have been punted to like a vascular clinic like where I was working. It can go to any of those. And when you send that fax, right, if it goes to the cardiologist and it's supposed to go to the family care provider, like it just kind of goes, goes nowhere, right, from there. So I think it's a really good idea to find out who prescribed it last. If the patient doesn't know who prescribed their blood thinner last, you can call their pharmacy. I call pharmacies all day long.   I have noticed in the last year, they are way easier to get a hold of, which has made my job a lot easier, working on the insurance portion. So reaching out to the pharmacy, finding out who that provider is and sending it to them, because they should be able to help with that. I thought that was a good shift in verbiage that you had of asking instead of like the cardiologist, because that's who you would assume was the one. But you said like so many times you guys would take care of them, and then they go back to family practitioner, and you guys would get the clearances, but you couldn't clear because you weren't overseeing. So just asking the patient.   who prescribed their medication for them last time. That way you can send the clearance to the correct provider. then- And they might not know. You know patients, right? They're like, I don't know, my mom's or else, I don't know who gave it to me. Somebody told me I need to be on this. But at least that could be another quick thing. And then also we were talking last night about-   ⁓ What are some other things that dentists can do when like writing scripts to help them get what I think like overarching theme of everything we discussed is one how to help dentists have less I think drag through pharmacy. ⁓ Because pharmacy can take a little while and so perfect we now know the difference between anti-quag and anti-platelet. We know which medications are probably safe. We know we can check the ADA guidelines so that we were not having to do as many clearances. We also know if they're on a medication to find out and we do need a clearance.   who we can go to for the fastest, easiest result. And now, in talking about prescriptions, you had some really interesting tips that you could share with them. Yeah, so with writing prescriptions, right, pharmacies are pharmacies. So I'm not gonna say good thing or bad thing. There are challenges working with pharmacies. I'm not gonna play that down at all. ⁓ If you're writing prescriptions and having issues and kickbacks from pharmacies, there's some interesting laws around ⁓ writing prescriptions. Say that you're trying to ⁓ prescribe   augmentin, you know, 875 BID, and you tell the patient, hey, I want you to take this twice a day for seven days, and then you put quantity of seven, because you're moving fast, right? You want it for seven days, quantity of seven. Quantity would actually be 14, right? It's not that big of a deal. Anybody with common sense would say if you're taking a pill for twice a day for seven days, you need 14 tablets. But LAHA doesn't allow pharmacists to make that kind of a change, unfortunately. They have to follow what you're saying there. So you're going to get a...   An annoying callback that says, you wrote for seven tablets. I know you need 14. Is that OK? Just delays things, right? So ⁓ I really like the two letters QS. That's Q isn't queen. S isn't Sam. Yeah. It stands for quantity sufficient. So you don't have to calculate the amount of any medication that you're doing. So for me, as a pharmacist, when I was taking care of patients, I hated calculating the amount of insulin they would need for an entire month. So I would say.   Mrs. Jones needs 15, I'd say 15 units ⁓ QD daily. ⁓ And then I say QS, quantity sufficient, ⁓ 90 day supply through refills. So the pharmacy can then go calculate how much insulin that they need. I don't have to even do that. So anytime you're prescribing anything, I like that QS personally. So that lets the pharmacy use ⁓ common sense, as I like to call it, instead of giving you a call. I think that's super helpful. I also thought of one thing too.   going back to blood thinners is when it's kind of like a real quick, like they're not gonna have you stop the blood thinner at all. like you're seeing if you can stop the blood thinner for a patient, there's some instances it's just not gonna happen. And that's whenever they've been, they've had a clot or a stroke or a heart attack within the last three months. Three months. Yeah, that's kind of like the.   Because so many people are like, they had a heart thing like six years ago. And so I think a lot of my dentists that I worked with were like, we got to stop the blood thinners. But it sounds like it's within three months. Yeah, well, I'm just the time. Like this is general broad strokes. What I'm just trying to say is when you want to expect a no real quick. Got it. Right. So because benefits of stopping a blood thinner within those first three months of an event is very, very risky versus the, you know, the benefit of reducing a little bit of blood coming out of the mouth. Right. Like that's not that bad.   when somebody's had a stroke or a heart attack or pulmonary embolism, a clot in the lung, like we can't replace the lung, heart or brain very easily. We can replace blood a lot better. We've got buckets of it at most hospitals have buckets of it, right? So I'm always kind of leaning towards I'd rather replace blood than tissue at all times. So that's kind of a quick no. If they've had one those events in the last three months, we are really, really gonna watch their brain instead of getting.   root canal, right? Like really worried about them. So you'll just say no. And they could the dentist still proceed with the procedure or would you recommend like a three month wait? Or is it provider specific way the pros and cons because sometimes you need to get that tooth out. Great question. think then it's going to come into clinical. That's that's when you send in the clearance, right? Like, and it's great to reach out to the provider who's managing it for you. But I think it's kind of good to know exactly when you get a quick no quick no is going to be less than three months.   ⁓ Or when it's going to be like a kind of a typical, yeah, no problem. If it's been no greater than six months, they're on the typical anticoagulants or alto eloquence. Nothing crazy is going on for them. You're only removing two teeth. This is very, very low risk. But again, I'd urge everybody to read the ADA guidelines. That way you feel more comfortable with it. I'm not as eloquent as they do. They do a real good job. So I don't want to take any of their credit. I think they do a real good job of simplifying that and making you feel confident with providing.   more timely care for patients. Which is amazing. And Jayce, one last thing. I don't remember what it was. You were talking about the DEA and like six month rule. yeah. Let's just quickly talk about that and then we'll wrap this because this is such a fascinating thing for me last night. Yeah. So when comes to prescribing controlled substances, most providers have to have a DEA license. OK. First of all, though, what's your take on dentist prescribing controlled substances? ⁓ I don't think, you know, I worked on the insurance side of things. Right. And I look at the requirements for the   as the authorizations, what a patient, the criteria a patient needs to hit in order to qualify for certain medications. A lot of times for those controlled substances, they have pretty significant issues going on, like fibromyalgia or cancer-related pain or end-of-life care versus we don't, in all my scanning thread, I don't have a ⁓ perfect picture memory. Sure. But I don't usually see oral.   pain in there. There is some post-operative pain that can be covered for those kind of medications but I really recommend to keep those lower and in fact in a lot of our criteria it recommends you know have they tried Tylenol first, they tried, have they filled NSAIDs or are they contraindicated with the patient. So really they should be last line for patients in my two cents but there's always going to be a caveat to the rule right? Of course. comes through that has oral cancer and you're taking   like that would make sense to me. Got it, so then back to the DEA. Yeah, okay. Okay, ready. So as a provider, you should be checking the, if you're doing controlled substances, you should be checking the prescription drug monitoring program, or sometimes called the PDMP, looking to see if patients are getting ⁓ controlled substances from another provider. So it's really just a check and balance to make sure that they're not going from provider to provider to getting too many narcotics and causing self harm or harm to others.   And so with checking that PDMP before prescribing, I think a lot of providers do that. A lot of softwares that I'm aware of, EMRs, electronic medical records, sometimes have links so that you can do that more quickly. However, I don't think it's as intuitive that they need to be checking that every six months in some states. And like here in Nevada, you're supposed to be checking it every six months, not for a patient, but for your actual DEA registration to see if anybody else is prescribing underneath you. Because if you don't check that every six months, you could get in some serious trouble with...   not only DEA, but even more the Board of Pharmacy and your state. Now, I don't know all 50 states, so I check with your state to see if you need to be checking that every six months, but set an alarm just to check that real quickly, keep your nose clean. ⁓ I've had providers, I've had to remind to do that. And if somebody was using your account, prescribing narcotics, you'd never know unless you went and checked that PDMP.   Yeah, I remember last night you were like, and if that was you, I would not want to be you. The Board of Pharmacy is going to be real excited to find you. So that was something where I was like, got it. So, and we all know I'm big on let's make it easy. And Jason, I love that you love this so much and you just brought so much value today. And like also for me, it's just fun to podcast. fun. Yeah. But I got a nerd out on my world a little bit. Bring it into yours. I work with dentists or at least you know, when I was working in Vascular Clinic all day long. Great questions that would come through. Yeah.   So I think for all of us, as a recap on this is number one, I think setting yourself ⁓ some cadences. So maybe every quarter we check our ADA guidelines and we check our, what is it, PDMP. PDMP. so each state, so they call it Prescription Drug Monitoring Program. We need that. Yeah, but there are different acronyms in different states, though. That's just what it's called in Nevada. I forget what it is in California, but you can check your state's prescription monitoring program, make sure that opioids aren't being prescribed under your name. Got it. So we just set that as a cadence.   We know one to three teeth most likely if they're on a blood thinner is According to the 88 as of today is good to go You know things that are going to get a quick know are going to be within the last three months of the stroke the heart attack or the Clot I'm thinking like the pulmonary embolus. Yeah, that's what we're trying to prevent   Those are gonna be quick knows and then if we're prescribing, let's do QS. We've got quantity is sufficient so that we're not getting phone calls back on those medications that we are. And then on narcotics, just being a bit more cautious. Of course, this is provider specific and in no way, or form did Jason come on here to tell you you are the clinical expert.   Jason's the clinical expert on medications. And if you guys ever have questions, I know Jason, you geek out and you want to talk to people so that anyone wants to chat shop. Be sure to reach out and we'll be able to connect you in. we've even talked about possibly, so let me know listeners. You can email in Hello@TheDentalATeam.com of ask a pharmacist anything. I talked to Jason. I was like,   We'll just have them like send in questions and maybe get you back on the podcast or we do a webinar. But any last thoughts, Jace, you've got of pharmacy and dentistry as we as we wrap up today? No, I think that's pretty much it. So check the ADA guidelines. I think it's really good to have cross communication between professions. Right. If you're working with the pharmacy, CVS, Walgreens or something like that or Walmart, I know that it can be challenging. Right. They're under different pressures. You're under different pressure. So I think ⁓ just coming in with an understanding, not being angry at each other.   you know what mean, is super beneficial and working together. When it comes to it, every dentist that I've talked to is actually worried about their patient. Every pharmacist that I've worked with is really worried about the patient as well. So we're trying to accomplish the same thing, but we have different rules and our hands are bound in different ways that annoy each other, right? Like I know Dr. Jones, want 14 tablets, but you said seven. And I know Common Sense says I should give them 14, but I've got to make that change.   knowing that their hands are tied by the law. They can't use as much common sense, which is aggravating. I mean, that's why I love what I gotta do here. I gotta just kind of help a lot more and use common sense and improve patient care. But those kinds of things I think are really beneficial as you work together and then not being so afraid of blood thinners, right? So I think those guidelines do a great job of giving you confidence and not worrying about the side effects. And there's a lot of things that you can do locally for bleeding.   You have a lot of control over that. I think that's pretty cool, the tools they have. Yeah. And at the end of the day, yes, you are the clinician. You are the one who is responsible for this. so obviously, chat, but I think collaborating, talking to other pharmacists, talking to them in your state, finding out what are the state laws, things like that I think can be really beneficial just to give you peace of mind and confidence. And again, dentistry, are maybe a bit more risk adverse because luckily we don't have patients dying That's great thing. Yeah, that's fantastic. I want my dentists to be risk adverse. I think so too. But Jason, I appreciate you being on the podcast today.   And for all of you listening, ⁓ more confidence, more clarity, more streamline to be able to serve and help our patients better. if we can help you in any way or you've got more questions, reach out Hello@TheDentalATeam.com. And as always, thanks for listening. I'll catch you next time on the Dental A Team podcast.  

During the first wave of the opioid pandemic, the U.S. federal government encouraged states to establish prescription drug monitoring programs (PDMPs) which use predictive algorithms to determine risk scores for patients. These scores, which can point correctly or inaccurately to substance use disorder (SUD), drug diversion, doctor shopping or drug misuse, have a risk themselves, as overreliance on PDMP information for clinical decision making often influences clinicians in their treatment, or refusal to treat, vulnerable people. In this episode, we speak with health law and policy expert Elizabeth Pendo, UW Law's senior associate dean for academic affairs and Kellye Y. Testy Professor of Law. Pendo, who co-wrote the recently published paper, “Challenging Disability Discrimination in the Clinical Case of PDMP Algorithms” in the Carolina Law Review, challenges PDMP algorithmic discrimination, which is far from regulated, as disability discrimination through the lens of federal antidiscrimination laws. Pendo also talks about the revitalization of UW Law's Health Law program through the upcoming launch of the Health Law & Policy Program.  

I'd LOVE to hear from you! Now you can send a TEXT MESSAGE! Be sure to leave your contact EMAIL so I can return your message!In this episode of "My DPC Story," host Dr. Maryal Concepcion speaks with Dr. Amber Beckenhauer about the intricate dynamics of managing staff in a Direct Primary Care (DPC) setting. Dr. Beckenhauer delves into her years of working with staff in her DPC and she shares about the challenges posed by a long-term employee's departure and the subsequent training of new staff to manage critical tasks like PDMP database submissions. She explores the balance between task delegation and maintaining efficiency, emphasizing the need for a dedicated office manager to streamline administrative duties. The conversation highlights the impact of staff turnover, the potential of virtual assistance versus the value of personal recognition in rural practices, and the ongoing reevaluation of standard operating procedures. Dr. Beckenhauer also discusses the advantages of the DPC model, including flexibility and personalized patient care. The episode provides valuable insights into strategic hiring, staff training, and maintaining a supportive workplace culture. Don't miss out on this episode full of practical tips for DPC practitioners. Subscribe and leave a review on "My DPC Story Podcast" to stay updated with the latest episodes.* DrChrono seamlessly integrates patient engagement with scheduling, clinical workflow, and medical billing, allowing you to manage your practice wherever you go. START YOUR FREE TRIAL TODAY! * HINT CLINICAL: Purpose-built by and for DPC clinicians, it is an all-encompassing EMR combining Hint's existing billing and membership management software with a clinical interface. LEARN MORE TODAY! -> SPRUCE HEALTH: NEW USERS get 20% off your SPRUCE HEALTH paid plan with code: MARYAL20Support the showBe A My DPC Story PATREON MEMBER! SPONSOR THE PODMy DPC Story VOICEMAIL! DPC SWAG!FACEBOOK * INSTAGRAM * LinkedIn * TWITTER * TIKTOK * YouTube

Today we listen to a conversation that began at the North Carolina Hospital Association's winter meeting between Bamboo Health Senior Director of Growth, Ellen Solomon, and CHESS Director of Value-based Operations, Rachel Holder. Ellen and Rachel get together for the podcast to continue the discussion on the topic of Navigating Value-based Care through Real Time Intelligence.RH: Thanks so much, Ellen, for joining us today. So can you give us a really brief introduction about yourself, your role, and tell us a little bit about Bamboo Health?ES: Yeah, sure. Thank you so much for having me, Rachel. It was great getting to chat with you at the North Carolina Healthcare Association winter meeting. But for folks that don't know me, my name is Ellen Solomon. I'm senior director of National Health System growth at Bamboo Health. I've been here for six years and I currently live in Charlotte, but I always love calling out to my North Carolina customers. I was born and raised in a small town of Reidsville, NC And so in terms of what we do, folks in North Carolina may remember us as patient ping or Appriss Health. We've since come together and rebranded as Bamboo Health back in 2021. And I'll first start again with sort of who we are at a very high level and then I'll go into North Carolina as well as obviously how we work with you guys, Rachel. But in one sentence, Bamboo Health is an intelligent care collaboration network across all 50 states. The problem we work to solve is that as you know better than me, healthcare was built on silos. Those silos could be the EMR that you use, your geographic location, state lines or the setting of care, whether that's acute post, acute, ambulatory. And those silos make engaging patients and coordinating care in real time very difficult. And even more difficult when you're actually trying to bend the cost curve and improve patient outcomes like readmissions, Ed utilization, post acute length of stay and many others. And so in short, I compare Bamboo Health to expedia.com. You have all these hotel chains, you have all these airline companies that are competing for your business. They operate their own platforms, their own tools and they don't really want to share with each other. But Expedia brings them together in a really simple way and that's where Bamboo Health sits. And so today in North Carolina, we support our customers really in three use cases. The first one which we'll drill into more I believe in, in this discussion and how chess uses Bamboo is we enable value based care use cases through our engaged admission discharge and transfer or ADT network. And in North Carolina specifically over 80% of the hospitals in the state participate. We have over 800 post acutes, over 50 provider organizations. And this actually started back in 2017 when we partnered with NCHA who's really been instrumental in helping us build out this ENGAGE network. That network does extend to all 50 states. Secondly, we partner with the state of North Carolina as well as 45 other states to support prescription drug monitoring or PDMP program to help continue to curb the opioid epidemic. And then lastly, we're rolling out a behavioral health referral network also known as BH scan in the state. So I think the, So what their common thread between all those use cases is it's real time actionable and through an engaged network. And so Rachel, I know when we spoke at NCHA, Chess has been such a long standing bamboo partner. You all have really been with us from the beginning. I'd love if you could share more about some of the challenges you're hearing from your value partners as they're transitioning into more risk and value based care.RH: Yeah. Thanks so much Ellen. So I think gone are the days that just a high AWV rate and some...

In this episode of Framework Focus, host Dr. Mark Fulton engages with Jean Hall and Brandi Van Patton from LogiCoy to unravel the significance of Prescription Drug Monitoring Programs (PDMPs) in Long-Term Care Pharmacy. Explore how PDMPs contribute to preventing diversion, ensuring patient safety, and addressing the opioid crisis. The episode delves into the specific impact of PDMPs on LTC, covering transitions of care, collaboration among providers, and the evolving role of LTC in this space.  The episode concludes with practical advice for pharmacies on navigating PDMPs.  Host: Dr. Mark Fulton & Guests: Jean Hall, Program Director, PDMP Solutions, Logicoy & Brandi Van Patton, Pharmacy Informatics, Logicoy New boost

Listen as Vanila M. Singh, MD, MACM, and Theresa Mallick-Searle,MS, PMGT-BC, ANP-BC, provide thoughtful answers and clinical insights to audience questions that were submitted at a recent webinar about developing individualized pain treatment plans. Topics covered in this podcast include risk assessment, navigating the balance between “law enforcement” and “healthcare professional” when prescribing opioids, and prescription drug monitoring programs.Presenters:Vanila M. Singh, MD, MACMClinical Associate ProfessorStanford University School of MedicinePalo Alto, CaliforniaFMR Chief Medical OfficerUS Department of Health and Human ServicesChairpersonCongressionally Mandated Pain Task ForceTheresa Mallick-Searle, MS, PMGT-BC, ANP-BCAdult Nurse PractitionerDivision Pain MedicineStanford Health CareRedwood City, CaliforniaThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please seehttps://bit.ly/3mgrfb9 for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC and in partnership with the American Academy of Physical Medicine and Rehabilitation, Alliance to Advance Comprehensive Integrative Pain Management, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi 

Listen as Amanda Zimmerman, PA-C, and Chin Hwa (Gina) Dahlem, PhD, FNP-C, answer audience questions that were submitted at the June 2023 webinar titled, “Safe and Smart: Teaching Patients About Safe Opioid Practices.” Their answers cover topics including how to conduct a pill count and cost concerns regarding naloxone. Presenters: Chin Hwa (Gina) Dahlem, PhD, FNP-C Clinical Associate Professor School of Nursing University of Michigan Nurse Practitioner Packard Health Ann Arbor, Michigan Amanda Zimmerman, PA-C Physician Assistant West Forsyth Pain Management Winston-Salem, North Carolina This activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please see https://bit.ly/3mgrfb9 for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA. Provided by Clinical Care Options, LLC and in partnership with the American Academy of Physical Medicine and Rehabilitation, Alliance to Advance Comprehensive Integrative Pain Management, Practicing Clinicians Exchange, and ProCE. Link to full program: https://bit.ly/44wOqkc

Listen as Amanda Zimmerman, PA-C, and Chin Hwa (Gina) Dahlem, PhD, FNP-C, answer audience questions that were submitted at the June 2023 webinar titled, “Safe and Smart: Teaching Patients About Safe Opioid Practices.” Their answers cover topics including how to conduct a pill count and cost concerns regarding naloxone.Presenters:Chin Hwa (Gina) Dahlem, PhD, FNP-CClinical Associate ProfessorSchool of NursingUniversity of MichiganNurse PractitionerPackard HealthAnn Arbor, MichiganAmanda Zimmerman, PA-CPhysician AssistantWest Forsyth Pain ManagementWinston-Salem, North CarolinaThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please see https://bit.ly/3mgrfb9 for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC and in partnership with the American Academy of Physical Medicine and Rehabilitation, Alliance to Advance Comprehensive Integrative Pain Management, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi 

Host: Patty Lavely, CIO Consultant and Co-chair, CHIME Opioid Task Force Guest: Mike Burger, Senior Consultant, Point-of-Care Partners What you'll learn about: - High level overview of the ambulatory EHR landscape. - If the standard software on the market today provides “opioid tools” to help providers manage patients that are taking opioids or are high risk for addiction/overdose.- - Third-party software to improve the capabilities including PDMP integration. - How it all fits (or doesn't) within the clinical workflows in the office. - If EHRs are typically tied into community services to support patients with SUD. - Technology differences between independent physician practices vs those owned by health systems/hospitals, and if there's a difference in how they're able to determine the patients at risk. -Whether, like hospitals, physician practices have come a long way with reducing opioid prescriptions; and if the software has functionality to support changing ordering practices. - The percentage of physician practices contributing data and viewing data via an HIE (in Mike's experience). - What health IT leaders do to mitigate the challenges in utilizing the technology to assist with better opioid stewardship and managing patients at risk. The CHIME Opioid Task Force (OTF) was launched in early 2018 with a simple mission: to turn the tide on the opioid epidemic using the knowledge and expertise of the nation's healthcare IT leaders. While our mission is simple, achieving it is not. Opioid addiction is a complex disease that requires long-term, if not lifetime, care from well-informed clinicians who are supported with easy-to-use and reliable tools.

Learning how to speak Spanish can help build relationships and take your farm to the next level.  Spanish instructor Katie Dotterer and dairy farmer Walt Moore share the impact and how to get started with learning Spanish. Dairy Stream host Joanna Guza dives into the topics below with Katie and Walt: 2:03: Impact of learning Spanish 5:02: Vulnerability of learning Spanish 6:33: Learning Spanish and turnover rate 7:40: Encouraging non-Spanish speaking employees to learn Spanish     9:25: Important to bring a fluent Spanish speaker to the farm 13:33: Cultures and traditions of Spanish speakers 16:40: Embracing the Spanish culture on your farm 18:35: Spanish resources in the community 23:42: Mindset with learning Spanish  26:35: Challenges with learning Spanish 28:30: How long does it take to learn Spanish 31:30: How to continue learning and practicing Spanish 34:35: Dialects and slang of the Spanish language   36:27: Encouraging Spanish-speakers to learn English 39:45: Advice for learning Spanish Special thanks to The Nature Conservancy of Wisconsin for sponsoring this episode. About the guests Meet Katie Dotterer: A life-long advocate for agriculture and education, Katie enjoys finding ways to infuse the two together. Her love for agriculture and the Spanish language developed through her upbringing as part of the third generation on her family's dairy farm in central PA. Katie has degrees in Business Management and Marketing, Secondary Education, and Spanish, and is certified in ESL: English as a Second Language. Recognizing a need to bridge an industry wide communication gap, she developed online Spanish Courses tailored specifically to agriculture, through her educational and advocacy business, AgvoKate (a play on her name & advocating for agriculture). Additionally, she rarely turns down an opportunity to advocate and engage with the 98% of the population who are removed from agriculture. She has done this through on-farm tours (in-person and virtual) when she co-owned and operated a dairy farm as a first-generation farmer, public speaking engagements, news segments and through her social media platforms. When she's not teaching or advocating, Katie loves traveling, dancing, playing piano and guitar, history, palm trees, dark chocolate and tea! Learn more about Katie's online Spanish courses here or email her at katiedotterer@agvokate.com. Walt Moore: Walt is President and General Manager of Walmoore Holsteins, Inc. The family farm has been in operation over 113 years and 5 generations.  Walt is in partnership with his wife Ellen.  Walmoore Holsteins, Inc. milks 1050 cows with a 31,000-pound herd average (producing in excess of 3.6 million gallons of milk annually), raises 880 replacement young stock, 100 Wagyu crosses, farms 1700 acres of corn for silage and grain, alfalfa, soybeans and Triticale.  Walmoore employs 15 full time and several part-time people.  Walt is also the General Partner of Moore Family Farm LP which was formed as a land holding company.  Additionally, Walt and Ellen with partners Duane and Marilyn Hershey started Moocho Milk Transportation Inc. in 2006 to haul their own milk.  Walt and Ellen along with Son Jake and his wife own Moore Meats LLC a premium American Wagyu farm to fork beef company.  Walt has traveled to other states and China helping to educate other producers on Best Management Practices.  Walt also serves on several committees including the Chester County Conservation District Board, London Grove Friends Finance Committee, American Dairy Coalition currently serving as President and On the Center for Dairy Excellence Board currently serving as President. He also served on the PDMP board as the Vice-President and President.  Walt also enjoys spending time with his family, attending PSU football games, hunting, boating and traveling.  This podcast is co-produced by the Dairy Business Association and Edge Dairy Farmer Cooperative, sister organizations that fight for effective dairy policy in Wisconsin and Washington, D.C.  Become a sponsor, share an idea or feedback by emailing podcast@dairyforward.com. 

The Dairy Streamlet is a new, condensed version of Dairy Stream that takes the long episode and covers just the high-level points of the conversation. If this topic interests you, we encourage you to listen to the July 26 episode.  Dairy Stream host Joanna Guza talked with Spanish instructor Katie Dotterer and dairy farmer Walt Moore about the impact of speaking Spanish and how to get started with learning the language. Special thanks to The Nature Conservancy of Wisconsin for sponsoring this episode. About the guests Meet Katie Dotterer: A life-long advocate for agriculture and education, Katie enjoys finding ways to infuse the two together. Her love for agriculture and the Spanish language developed through her upbringing as part of the third generation on her family's dairy farm in central PA. Katie has degrees in Business Management and Marketing, Secondary Education, and Spanish, and is certified in ESL: English as a Second Language. Recognizing a need to bridge an industry wide communication gap, she developed online Spanish Courses tailored specifically to agriculture, through her educational and advocacy business, AgvoKate (a play on her name & advocating for agriculture). Additionally, she rarely turns down an opportunity to advocate and engage with the 98% of the population who are removed from agriculture. She has done this through on-farm tours (in-person and virtual) when she co-owned and operated a dairy farm as a first-generation farmer, public speaking engagements, news segments and through her social media platforms. When she's not teaching or advocating, Katie loves traveling, dancing, playing piano and guitar, history, palm trees, dark chocolate and tea! Learn more about Katie's online Spanish courses here or email her at katiedotterer@agvokate.com. Walt Moore: Walt is President and General Manager of Walmoore Holsteins, Inc. The family farm has been in operation over 113 years and 5 generations.  Walt is in partnership with his wife Ellen.  Walmoore Holsteins, Inc. milks 1050 cows with a 31,000-pound herd average (producing in excess of 3.6 million gallons of milk annually), raises 880 replacement young stock, 100 Wagyu crosses, farms 1700 acres of corn for silage and grain, alfalfa, soybeans and Triticale.  Walmoore employs 15 full time and several part-time people.  Walt is also the General Partner of Moore Family Farm LP which was formed as a land holding company.  Additionally, Walt and Ellen with partners Duane and Marilyn Hershey started Moocho Milk Transportation Inc. in 2006 to haul their own milk.  Walt and Ellen along with Son Jake and his wife own Moore Meats LLC a premium American Wagyu farm to fork beef company.  Walt has traveled to other states and China helping to educate other producers on Best Management Practices.  Walt also serves on several committees including the Chester County Conservation District Board, London Grove Friends Finance Committee, American Dairy Coalition currently serving as President and On the Center for Dairy Excellence Board currently serving as President. He also served on the PDMP board as the Vice-President and President.  Walt also enjoys spending time with his family, attending PSU football games, hunting, boating and traveling.  This podcast is co-produced by the Dairy Business Association and Edge Dairy Farmer Cooperative, sister organizations that fight for effective dairy policy in Wisconsin and Washington, D.C.  Become a sponsor, share an idea or feedback by emailing podcast@dairyforward.com. 

State Sen. Holly Rehder (R-Scott City) is a veteran lawmaker in Jefferson City. She's served more than 11 years in the Missouri Legislature: eight in the House and three in the Missouri Senate. She's launched her candidacy for lieutenant governor and says she wants to unabashedly protect sacred Christian and conservative values. One of her landmark bills that was signed into law in 2021 was bipartisan prescription drug monitoring program (PDMP) legislation. Senator Rehder joined us live on 939 the Eagle's "Wake Up Mid-Missouri", telling listeners that more than 70 percent of Missourians support PDMP. She also says her constituents in southeast Missouri back her transgender bill that becomes law on August 28. It requires athletes to participate in male or female competitive sports based on their gender at birth, through the collegiate level:

Host: Kevin Smith Dives into the weekly news most impactful to the HeartlandHEADLINESA $24B Michigan budget for schoolsMichigan Advance - https://michiganadvance.com/2023/07/05/heres-whats-in-the-24b-michigan-budget-for-schools/Batteries And Renewables Are Saving Texas During The Heat WaveForbes - https://www.forbes.com/sites/anandgopal/2023/07/02/batteries-and-renewables-are-saving-texas-in-the-heat-wave/?sh=6727f65621ddLIGHTNING ROUNDMissouri,Medicaid recipients in Missouri are now at risk of losing their health insurance coverage https://news.stlpublicradio.org/health-science-environment/2023-07-03/missouri-begins-disenrolling-medicaid-patients-after-three-year-freezeMissouri's new prescription drug monitoring program (PDMP) will allow physicians and pharmacists to track a patient's prescriptions.https://fox2now.com/news/missouri/missouris-prescription-drug-monitoring-program-to-launch-soon/Arkansas,Sanders Slashes State Worker Raiseshttps://www.kark.com/news/state-news/state-employees-protest-on-arkansas-state-capitol-steps-about-pay-raise-policies/Sanders Seeks Stacked Supreme Court https://apnews.com/article/huckabee-sanders-arkansas-supreme-court-hiland-republicans-e89a6ee9f7640b1687c1f52dd5e0a9d5Ohio,Groups hoping to enshrine abortion rights in Ohio's constitution delivered nearly double the number of signatures needed to place an amendment on the fall statewide ballot.https://apnews.com/article/abortion-rights-ohio-ballot-constitutional-amendment-88bddf55dc5f08201c8efe1f3093d1b5And Lastly,Sen Josh Haulin' Ass Hawley gets it wrong

Host: Kevin Smith Dives into the weekly news most impactful to the HeartlandHEADLINESA $24B Michigan budget for schoolsMichigan Advance - https://michiganadvance.com/2023/07/05/heres-whats-in-the-24b-michigan-budget-for-schools/Batteries And Renewables Are Saving Texas During The Heat WaveForbes - https://www.forbes.com/sites/anandgopal/2023/07/02/batteries-and-renewables-are-saving-texas-in-the-heat-wave/?sh=6727f65621ddLIGHTNING ROUNDMissouri,Medicaid recipients in Missouri are now at risk of losing their health insurance coverage https://news.stlpublicradio.org/health-science-environment/2023-07-03/missouri-begins-disenrolling-medicaid-patients-after-three-year-freezeMissouri's new prescription drug monitoring program (PDMP) will allow physicians and pharmacists to track a patient's prescriptions.https://fox2now.com/news/missouri/missouris-prescription-drug-monitoring-program-to-launch-soon/Arkansas,Sanders Slashes State Worker Raiseshttps://www.kark.com/news/state-news/state-employees-protest-on-arkansas-state-capitol-steps-about-pay-raise-policies/Sanders Seeks Stacked Supreme Court https://apnews.com/article/huckabee-sanders-arkansas-supreme-court-hiland-republicans-e89a6ee9f7640b1687c1f52dd5e0a9d5Ohio,Groups hoping to enshrine abortion rights in Ohio's constitution delivered nearly double the number of signatures needed to place an amendment on the fall statewide ballot.https://apnews.com/article/abortion-rights-ohio-ballot-constitutional-amendment-88bddf55dc5f08201c8efe1f3093d1b5And Lastly,Sen Josh Haulin' Ass Hawley gets it wrong

This episode is also available as a blog post: https://youarewithinthenorms.com/2023/05/05/letter-to-fda-in-support-of-center-for-u-s-policy-petition-to-ffor-immediate-termination-of-deas-narxcare-and-pdmp-systems-as-misbranded-dangerous-and-c/

This episode is also available as a blog post: https://youarewithinthenorms.com/2023/04/30/study-by-center-for-united-states-policy-shows-deas-pdmp-narxcheck-systems-used-by-nearly-all-hospital-and-pharmacies-to-be-misbranded-danger-to-healthcare-and-use-must-be-suspended-immediatel/

Listen as Vanila M. Singh, MD, MACM, and Theresa Mallick-Searle, MS, PMGT-BC, ANP-BC, provide thoughtful answers and clinical insights to audience questions that were submitted at a recent webinar about developing individualized pain treatment plans. Topics covered in this podcast include risk assessment, navigating the balance between “law enforcement” and “healthcare professional” when prescribing opioids, and prescription drug monitoring programs.Presenters:Vanila M. Singh, MD, MACMClinical Associate ProfessorStanford University School of MedicinePalo Alto, CaliforniaFMR Chief Medical OfficerUS Department of Health and Human ServicesChairpersonCongressionally Mandated Pain Task ForceTheresa Mallick-Searle, MS, PMGT-BC, ANP-BCAdult Nurse PractitionerDivision Pain MedicineStanford Health CareRedwood City, CaliforniaThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please see https://bit.ly/3mgrfb9 for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC and in partnership with the American Academy of Physical Medicine and Rehabilitation, Alliance to Advance Comprehensive Integrative Pain Management, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi  

Why is my doctor afraid to prescribe? Bev discusses a recent webinar by BJA TTAC - COSSAP - Bureau of Justice Assistance's Comprehensive Opioid, Stimulant, and Substance Abuse Program Resource Center. Link to their website and webinars The Doctor Patient Forum's Podcast Episodes on: Red Flags/Drug-Seeking Behavior PDMP/NarxCare - Part 1 PDMP/NarxCare - Part 2 PDMP/NarxCare - Part 3 PDMP/NarxCare - Part 4 Patient Abandonment and Forced Taper Questionnaire Disclaimer: The information that has been provided to you in this podcast is not to be considered legal or medical advice. --- Send in a voice message: https://anchor.fm/the-doctor-patient-forum/message Support this podcast: https://anchor.fm/the-doctor-patient-forum/support

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/11/04/stanford-speaker-series-jennifer-d-oliva-jd-discusses-flaws-in-prescription-drugs-surveillance-pdmp-ruan-v-united-states-decision-2/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/11/03/stanford-speaker-series-jennifer-d-oliva-jd-discusses-flaws-in-prescription-drugs-surveillance-pdmp-ruan-v-united-states-decision/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

This is part 4 in our NarxCare/PDMP series. We interview Jacob James Rich. This episode focuses on PDMP harms, law enforcement's access to the PDMP, and whether HIPAA protects patients from PDMP data being shared. Jacob James Rich is a researcher at the Cleveland Clinic Center for Evidence-Based Care Research, studying epidemiology and biostatistics at the Case Western Reserve University School of Medicine. Jacob also works as an analyst for Reason Foundation, focusing on healthcare policy. He has written extensively on drug policy topics, such as the consequences of prescription drug monitoring programs (PDMPs) on patient access and overdose mortality. Jacob is currently researching racial disparities in drug enforcement with CWRU Graduate Student Council's DEI Award. Brief: https://reason.org/policy-study/prescription-drug-monitoring-programs-effects-on-opioid-prescribing-and-drug-overdose-mortality/ Reason bio page: https://reason.org/author/jacob-rich/ Twitter: @jacobjamesrich Attorney Jennifer Oliva's article on PDMP and law enforcement in Duke Law Review - Prescription Drug Policing: The Right to Health Information privacy Pre- and post-Carpenter Links to topics mentioned: Opioid Rapid Response Program content on The Doctor Patient Forum Website OIG Toolkit Links to podcasts or presentations in their entirety that were shared in this podcast - NASCA - "State PDMP vs National PDMP" Cover 2 Resources - "Strike Force Stops Flow of Illicit Opioids" Cato Institute - "Patients, Privacy, and PDMP's" NPR show 1A - "Against the Pain - The Opioid Crisis and Medication Access" Kate Nicholson's bio - "Kate Nicholson, JD, is a civil rights attorney and a nationally-recognized expert on the Americans with Disabilities Act (ADA). She served in the U.S. Department of Justice for 18 years, where she litigated and managed cases, coordinated federal disability policy, and drafted the current ADA regulations." - Executive Director at NPAC Kate developed intractable pain after a surgical mishap left her unable to sit or stand and severely limited in walking for many years. She gave the TEDx talk, What We Lose When We Undertreat Pain, and speaks widely at universities and conferences and to medical groups." Disclaimer: The information provided to you in this podcast is not to be considered medical or legal advice. --- Send in a voice message: https://anchor.fm/the-doctor-patient-forum/message

Claudia and Bev discuss PDMP's (Prescription Drug Monitoring Programs) and NarxCare with Atty. Jennifer Oliva. "Professor Oliva's research and teaching interests include health law and policy, privacy law, evidence, torts, and complex litigation. She has served as an invited peer reviewer for the American Journal of Public Health, Yale Journal of Health Policy, Law, and Ethics, American Journal of Law & Medicine, Journal of Law and the Biosciences, and Big Data & Society and her scholarship has been published by or is forthcoming in, among other publications, the California Law Review, Duke Law Journal, Northwestern University Law Review, UCLA Law Review, North Carolina Law Review, Ohio State Law Journal, George Mason Law Review, and online companions to the University of Chicago Law Review and New York University Law Review." Jenn is also on Jenn is on the Science and Policy Advisory Council for NPAC (National Pain Advocacy Center) Excerpts were played on this podcast that can be found in their entirety in the following links: NPR show 1A - "Against the Pain: The Opioid Crisis and Medication Access" "Patients, Privacy, and PDMP's" - Cato with Dr. Jeffrey Singer and Kate Nicholson Duke Margolis - "Strategies for Promoting the Safe Use of Prescription Opioids" NPR - "To End Addiction Epidemic" - Kolodny quote Cover 2 Resources - Gary Mendell Jennifer Oliva can be contacted on Twitter @jenndoliva Learn more about Jennifer on her website at uchastings Jennifer D. Oliva's paper: "Dosing Discrimination: Regulating PDMP Risk Scores" Disclaimer: The information provided to you in this podcast is not to be considered medical or legal advice --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/the-doctor-patient-forum/message

Hour 2 -  Dr. John Lilly and Nick Reed are live at Scramblers Diner for Heroes Breakfast. Here's what they cover: State Holidays for October. Government offices - Social Security and Medicare. Changes in physician employment due to COVID. PDMP update.

In this episode Claudia Merandi and Bev Schechtman interview Dr. Neil. He has put a tremendous amount of work into researching and analyzing NarxCare. Part 1 of NarxCare includes an introduction to NarxCare and an interview with Dr. Neil. Part 2 will come out next week and will have interviews with three women affected by NarxCare, and also portions of a talk show Bev and Maia Szalavitz were on called 1A with NPR. The following information can be found on our website under FAQ's/What is NarxCare. Please check out that link for more links including the article in Wired by Maia, the patent for NarxCare, and the Ohio Study the ORS was based on. From The Doctor Patient Forum website: NarxCare, a product of a company called Bamboo Health, is a proprietary data analytics program. It uses up to 70 data points (that only Bamboo Health knows) and mixes them with your PDMP (prescription history) to assign four 3-digit scores letting your doctor or pharmacy know if you have a high risk of abuse or overdose. There is a Narcotic Score, a Stimulant Score, and a Sedative Score, and an Overdose Risk Score (ORS). According to Bamboo Health, "NarxCare aids care teams in clinical decision making, provides support to help prevent or manage substance use disorder, and empowers states with the comprehensive platform they need to take the next step in the battle against prescription drug addiction." Essentially, NarxCare pulls data from multiple state registries looking for red flags of drug seeking behavior. The three categories of prescription medication it looks at are narcotics (opioids), stimulants (ADHD meds) and sedatives (benzos, sleeping meds, etc.). "The NarxCare report identifies risk factors with interactive visualizations, as well as an Rx Graph, and a set of scores that numerically correspond to the patient's PDMP data." Although Appriss states on their website that their product shouldn't be used by itself to make medical decisions, that's not what's actually happening. As shown in this NarxCare article, patients are being denied medication or even being dismissed from a medical practice based on a NarxCare score alone. Some of the risk factors used in the proprietary algorithm are: The number of prescribers a patient has had in a two-year period. The number of pharmacies a patient used in a two-year period. The dosage (MME-Milligram Morphine Equivalent). Amount of other medications that may increase potency of other medications. Number of times prescriptions overlap with prescriptions from other providers. Any Mental Health Diagnosis Distance from patient to doctor Disclaimer: The information in this podcast is not to be considered medical or legal advice. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/the-doctor-patient-forum/message

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/06/18/the-pdmp-raising-issues-in-data-design-use-and-implementation-causing-thousands-of-deaths-billions-of-dollars-wasted-hundreds-of-doctors-in-america-being-falsely-and-wrongfully-imprisoned/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/05/22/the-deas-pdmp-dosing-discrimination-and-bias-targets-healthcare-providers-patients-based-on-skin-color-and-nation-of-orgin/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

In "Dosing Discrimination: Regulating PDMP Risk Scores," Professor Jennifer D. Oliva explores how risk scores from Prescription Drug Monitoring Programs can deter treatment for patients who are deemed to be at high risk of drug misuse, exacerbating discrimination against certain marginalized populations. Author: Jennifer D. Oliva is the Associate Dean for Faculty Research and Development, Professor of Law, and Director of the Center for Health & Pharmaceutical Law at Seton Hall University School of Law. Host: Carter Jansen Technology Editors: NoahLani Litwinsella (Volume 110 Senior Technology Editor), Carter Jansen (Volume 110 Technology Editor), Hiep Nguyen (Volume 111 Senior Technology Editor), Taylor Graham (Volume 111 Technology Editor), Benji Martinez (Volume 111 Technology Editor) Other Editors: Ximena Velazquez-Arenas (Volume 111 Senior Diversity Editor), Jacob Binder (Volume 111 Associate Editor), Michaela Park (Volume 111 Associate Editor), Kat King (Volume 111 Publishing Editor) Soundtrack: Composed and performed by Carter Jansen Article Abstract: Prescription drug monitoring program (PDMP) predictive surveillance platforms were designed for—and funded by—law enforcement agencies. PDMPs use proprietary algorithms to determine a patient's risk for prescription drug misuse, diversion, and overdose. The proxies that PDMPs utilize to calculate patient risk scores likely produce artificially inflated scores for marginalized patients, including women and racial minorities with complex, pain-related conditions; poor, uninsured, under-insured, and rural individuals; and patients with co-morbid disabilities or diseases, including substance use disorder and mental health conditions. Law enforcement conducts dragnet sweeps of PDMP data to target providers that the platform characterizes as “overprescribers” and patients that it deems as high risk of drug diversion, misuse, and overdose. Research demonstrates that PDMP risk scoring coerces clinicians to force medication tapering, discontinue prescriptions, and even abandon patients without regard for the catastrophic collateral consequences that attend to those treatment decisions. PDMPs, therefore, have the potential to exacerbate discrimination against patients with complex and stigmatized medical conditions by generating flawed, short-cut assessment tools that incentivize providers to deny these patients indicated treatment. The Federal Food and Drug Administration (FDA) is authorized to regulate PDMP predictive diagnostic software platforms as medical devices, and the agency recently issued guidance that provides a framework for such oversight. Thus far, however, the FDA has failed to regulate PDMP platforms. This Article contends that the FDA should exercise its regulatory authority over PDMP risk scoring software to ensure that such predictive diagnostic tools are safe and effective for patients.

This episode is also available as a blog post: https://youarewithinthenorms.com/2022/03/23/the-junk-science-and-fundamental-flaw-of-morphine-milligram-equivalent-mme-undermines-pdmp-and-dea-enforcement/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

In this episode, Andrew Friedman, MD, provides an overview of safe and effective opioid prescribing for patients with pain and walks through key points of opioid prescribing from the initial to final stages. Listen as he discusses development of a treatment plan and opioid selection, followed by tips for medication initiation and acute monitoring. Dr Friedman then expands on managing patients who progress from acute opioid use to subacute use, as well as chronic opioid use. Finally, the risks for overdose and importance of continuous risk assessment are discussed, along with considerations for opioid tapering and the utility of medication-assisted therapy for patients who develop opioid use disorder.  Presenter:  Andrew Friedman, MDMedical Director, Physical Medicine and RehabilitationVirginia Mason Franciscan HealthDirector, Spine Clinic and ServicesVirginia Mason Health CenterClinical Associate ProfessorUniversity of WashingtonSeattle, WashingtonThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please seehttps://bit.ly/3mgrfb9for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC, and in partnership with the American Academy of Physical Medicine and Rehabilitation, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi

Hour 2 -  Dr. John Lilly joins Nick Reed this morning for the Friday Road Show. Here's what they cover this morning: Dr. John Lilly covers the State Holidays for March. A quick game of Republican vs. Democrat. Dr. Lilly reads off proposed legislation in the House and Nick has to guess if it was a Republican or a Democrat. Feel free to play along at home. MAP test questions.  Dr. Lilly covers how questions are written, who writes them, and MAP test results throughout the last few years. Be careful what you ask for... Dr. John Lilly gives us an update on the PDMP. ESG vs. Free Market.

In this episode, Erik Shaw, DO, FAAPMR, discusses factors that should be reviewed before starting treatment with an opioid, as well as details on patient and provider responsibilities with opioid therapy. Listen as Dr Shaw interviews a patient with chronic pain to demonstrate application of these concepts in clinical practice.Presenter:  Erik Shaw, DO, FAAPMRChairAAPM&R Opioid Task ForceMedical DirectorShepherd Spine and Pain InstituteAtlanta, GeorgiaThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please seehttps://bit.ly/3mgrfb9for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC, and in partnership with the American Academy of Physical Medicine and Rehabilitation, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi 

In this episode, Erik Shaw, DO, FAAPMR, discusses factors that should be reviewed before starting treatment with an opioid and during follow-up appointments. Listen as Dr Shaw details both patient and prescriber responsibilities in opioid therapy initiation and maintenance, as well as strategies for setting appropriate goals with opioid therapy.Presenter:  Erik Shaw, DO, FAAPMRChairAAPM&R Opioid Task ForceMedical DirectorShepherd Spine and Pain InstituteAtlanta, GeorgiaThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please seehttps://bit.ly/3mgrfb9for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC, and in partnership with the American Academy of Physical Medicine and Rehabilitation, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi 

Hour 1 -  Dr. John Lilly fills in for the vacationing Nick Reed this morning. Here's what he covers: Dr. John Lilly airs his grievances on bad drivers. Dr. Lilly talks a little football. Annual police crime reports for the city of Springfield. In the crime reports, Springfield PD include several drugs, however, drug reports do not include fentanyl. Dr. Lilly finds the stats for deaths within the area due to fentanyl. Below are the stats for the last several years - 2012: less than 10. 2013: 10 2014: less than 10. 2017: 30 2018: 26 2019: 37 2020: 53 Dr. Lilly also covers the national stats for fentanyl overdoses. A PDMP update.

This episode is also available as a blog post: https://youarewithinthenorms.com/2021/12/21/the-london-briefs-the-prescription-drug-monitoring-program-pdmp-a-billion-dollar-fraudulently-database-of-doj-dea/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

PDMP and EPCS are two emerging abbreviations essential to curbing the current opioid epidemic. David McFarlane, Marketing Communications Manager with Medsphere, and Host Tyler Kern discussed what they are and their relevance.PDMP, or Prescription Drug Monitoring Programs, are state registries that track opioid administration by pharmacists. PDMPs are not implemented in every state and are not state-standardized. EPCS, or Electronic Prescriptions for Controlled Substances, is when providers send a prescription to a pharmacy and there is an electronic record that can link to the PDMP. Currently, PDMP and EPCS are not federally mandated. Twenty-two states lack one program while six lack either. This will likely soon change, as the government moves to enforce overarching requirements that could prevent addicted individuals from doctor shopping across state lines.A federal mandate would not change pharmacist workflow much if these programs are automated. In fact, implementation would benefit healthcare workers such as physicians. An ER physician might pull up a patient record and observe a history of their prescriptions on the registry to see if anything indicates addiction. McFarlane explained, “It also gives him or her a clear picture of where that patient sitting in front of him or her sits and what their real needs are.” This data is useful but there is no protocol for how to approach it in terms of funneling patients to rehab programs or administering weaning medications. McFarlane stated, “That's something that has to be discussed widely in the country in terms of programs, in terms of protocols for physicians in different hospitals.” As for next steps, McFarlane believes protocol standardization at the state level is achievable if small hospitals receive funding to implement opioid programs and comply with a mandate.Learn more about PDPM and EPCS and get in contact with McFarlane by visiting medsphere.com.

This episode is also available as a blog post: https://youarewithinthenorms.com/2021/11/22/warning-pdmp-how-your-medical-prescription-data-is-being-used-to-violate-your-constitutional-rights-in-every-pharmacy-in-america-a-podcast-with-cathleen-london-md-3rd-year-law-u-maine/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

This episode is also available as a blog post: https://youarewithinthenorms.com/2021/11/16/study-shows-prescription-drug-monitoring-programs-pdmp-violates-4th-amendment-rights-and-exacerbate-the-overdose-crisis-the-fugelsang-3/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/norman-j-clement/support

In this edition of the eClinicalWorks Podcast, host Brian Saal and eClinicalWorks's own Deb Wade discuss how the Prescription Drug Monitoring Program (PDMP) software in eClinicalWorks helps providers run drug checks and safely prescribe opioids and other controlled substances to their patients. They explore how eClinicalWorks works with prescription drug monitoring programs nationwide to ensure prescriptions are warranted and dosages are appropriate. With PDMP from eClinicalWorks, providers have the tools they need to comply with all state and federal regulations, discourage pharmacy shopping, and ensure effective pain control.

This episode focuses on Nebraska legislation that outlines rules for prescribing and continuing education around opioids and controlled substances. The legislation was passed in 2018, but its implementation was delayed because of COVID. However, these requirements are now in effect starting in October 2021. Among the requirements are that prescribers must obtain 3.0 hours of CME regarding prescribing opioids on a biennial basis (0.5 hours of which MUST cover Nebraska's Prescription Drug Monitoring Program or PDMP). Dr. Zacharias outlines the details of meeting these requirements, including accessing a half-hour PDMP training video on the Nebraska Department of Health and Human Services' website and upcoming online COPIC seminars that fulfill 2.0 hours of CME. There are two different COPIC seminars (each one is an hour) that provide risk management guidance around opioids, including the risks of addiction and overdose. The seminars are no-cost to attend, open to all Nebraska prescribers, and will be held on 9/28, 9/30, 10/12, and 10/14.

Introduction In this episode of the Post-Acute POV, our host Navin Gupta, SVP of the home and hospice division at MatrixCare, is joined by Rachel Petersen, Manager of Product Innovation, Medication History and PDMP at Surescripts, and Jill Lytwyn, Key Account Executive at Surescripts. The three discuss driving better patient outcomes via medication reconciliation in home care. Join Rachel, Jill, and Navin as they cover the issue of medication reconciliation, the genesis of Surescripts, and the Surescripts Network Alliance. Learn how their solution can help providers stop relying on manual processes and streamline transitions of care by reducing errors of admission, duplicate medications, and drug interactions. Listen to the episode below. Topics discussed during today’s episode: [00:38 – 02:49]: Navin introduces our guests, Rachel Petersen and Jill Lytwyn. [02:49 – 07:33]: Rachel and Jill provide their origin stories and what brought them to their current positions at Surescripts. [8:43 – 10:20]: Jill explains the genesis of Surescripts and the Surescripts Network Alliance. Through this alliance and Surescripts’ various partnerships, they have connected over two million health care professionals and organizations. [10:51 – 13:12]: Jill describes the issue of medication reconciliation and how obtaining medication history on a patient via technology streamlines transitions of care by reducing errors of admission, duplicate medications, and drug interactions. [10:24 – 16:07]: By using a medication reconciliation solution, Surescripts has seen an average of 45 minutes in time savings. This corresponds directly to cost savings for care providers. [16:56 – 18:25]: Rachel explains how understanding the “why” behind clinical decision-making can greatly improve data quality and drive better patient outcomes. [19:23 – 22:10]: Rachel describes the considerations that providers should be taking when making EHR decisions including selecting a platform that allows users to pull data from multiple sources. Resources Learn more about MatrixCare: https://www.matrixcare.com/ Find out more about Surescripts: https://surescripts.com/ Read the transcript of today’s episode Listen to more episodes of the Post-Acute POV Disclaimer The content in this presentation or materials is for informational purposes only and is provided “as-is.” Information and views expressed herein, may change without notice. We encourage you to seek as appropriate, regulatory and legal advice on any of the matters covered in this presentation or materials. ©2021 by MatrixCare

Health information exchange (HIE) is the mobilization of health care information electronically across organizations within a region or community. In 2009, Congress attempted to modernize HIE processes by passing the HITECH Act, offering grants and incentives to states and municipalities for developing regional HIE initiatives. Although there has been some progress toward effective mechanisms for data exchange, in many regions of the country it is no easier to share medical information than it was over a decade ago. That is not the case in the State of Nebraska and neighboring states where CyncHealth has achieved health care transformation through data democratization and community betterment collaboration.  They have done this by becoming more than a HIE; instead they have become a true “population health utility” by building the roads and the infrastructure for better workflows and better patient care (not just improved data exchange). This week, we are pleased to welcome three important guests from CyncHealth, Dr. Jaime Bland, President and CEO , Dr. Larra Petersen-Lukenda, Vice President of Population Health, and Dr. Joy Doll, Vice President of Community and Academic Programs. Their vision for a ‘population health utility' builds upon the ONC's vision for interoperability through data democratization and cross-sector collaboration. In this episode, we interview these leaders to better understand how to leverage data to create the greater good in societal health outcomes. You will hear from them how health care transformation can be realized through community partnerships and data sharing across the continuum of care, collaborative research in population health, and an empowered “health data competent workforce” to meet clinical and social needs in a more holistic way.   Episode Bookmarks: 03:45The purpose of a ‘population health utility' is to create better workflows and improved patient care, not just improved data exchange 04:45 Fewer than half of office-based physicians can exchange patient health information outside their organization electronically 05:30 The HIE market is projected to double from $1 billion in 2020 to $2 billion in only 5 years 06:00 Jaime discusses how CyncHealth's 15-year journey to build a HIE infrastructure to support population health in Nebraska 07:20 Jaime and Larra's vision for leveraging a HIE as the basis for a clinically integrated network/ACO 08:00 Improving upon the cumbersome query-based exchange model to deliver better patient outcomes in complex care scenarios 09:00 Jaime explains how they have reframed the HIE into a “population health utility” 09:40 Joy describes the application of the population health utility to address the Quadruple Aim and improve patient outcomes 10:25 Larra on reaching the ONC's 10-year vision for interoperability can improve clinical decision support and patient engagement 11:55 Larra on how “The ability to influence the future of healthcare through data is an amazing responsibility to benefit the greater good of the community.” 12:30 Jaime on the Nebraska Prescription Drug Monitoring Program (PDMP) -- a stand-alone medication query platform integrated into the CyncHealth HIE 16:15 Larra on the benefits of the PDMP in improving completeness of the overall medical record, with impact on patient safety and care interventions 18:30 The Opioid Crisis and SUD (23.4 million have SUD causing 81,000 drug overdose deathsannually -- two-thirds of which are related to opioids) 20:00 Jaime on how CyncHealth has responded to the Support for Patients and Communities Actin order to address the Opioid Crisis 21:15 Larra emphasizes the importance of the Support Act as a way to leverage technology in response to the national opioid epidemic 24:30 Joy on the opportunities for health policy and public sector funding to address disparities in care 27:30 Jaime on how transforming an HIE into a “Population Health Utility...

Happy Friday! Nick Reed and Tom Martz are live on location at Scramblers Diner. Here's what they covers this hour: Moments in history, Liberty Lecture series, PDMP, and MORE.

Kaitlyn is joined by guest host Hannah Beers Sutton, a senior associate with Axiom Strategies, to break down the U.S. Senate race as the GOP field gets a little more crowded with the entrance of Congresswoman Vicky Hartzler. The pair also discusses Rep. Travis Smith's involvement with the PDMP legislation and recaps session.

Nick Reed talks about a variety of topics in the news, including: Nick shares his thoughts on what happened on January 6th. Multiple websites went down this morning. Some of the sites include Reddit, CNN and The New York Times. Fastly, a cloud services company that hosts many of these sites cache, says it was a "service configuration." Are we experiencing another cyber attack? Speaking of cyber attacks, a New York City law department was attacked over the weekend. Missouri became the final state to approval the Prescription Drug Monitoring Program database.

State Rep Tony Lovasco and Austin Petersen discuss the news of the day from the Missouri legislature regarding PDMP. Tony also discusses cruise lines being mandated not to require a vaccine passport and other related issues.

Tom talks about several House bills: HB 578 & HB 583 ALSO - MO gas tax, as well as FIVE other tax increases.... And the latest PDMP update.

FIVE tax increases have been sent to Gov. Parsons desk... A PDMP was also sent to his desk. Gov. Parson announced that Missouri will join several states ending pandemic-related federal programs that include extra payments to unemployed workers. House Minority Leader Crystal Quade, D-Springfield, said in statement that Missourians refusing to work so they can collect unemployment is “an offensive, right-wing myth.” “Contrary to what the governor claims, the free market – not some federal boogeyman – is primarily responsible for Missouri's tight labor market.” Tom Martz calls in to talk about the MO gas tax. Dr. John Lilly gives us a call to chat about the PDMP.

Dr. Lilly gives us an update on the PDMP.

SB 63 – PDMP HB 449 – Designates the second Wednesday in May as Celiac Awareness Day. HB 402 – prohibits making lottery winner names from being public. HB 394 – Safety sales tax for Branson West, Clinton, Cole Camp, Hallsville, Lincoln, and Warrensburg. KY3 has an article titled “Missouri House votes to ban transgender athletes on girls teams.” Nick and Tom read the article and talk about how misleading the headline is.

Kaitlyn and Conner talk about Todd Graves' appointment to the UM System Board of Curators, Sen. Holly Rehder's PDMP bill, Rep. Ron Hicks' gun bill, Congresswoman Vicky Hartzler's potential run for U.S. Senate, the results from the St. Louis City municipal elections, and more. It's been a busy week in Missouri politics!

Good Wednesday morning! Nick Reed talks about a variety of topics, including: Former Gov. Eric Greitens on Monday expressed interest in running for the U.S. Senate seat held by Roy Blunt. ALSO - Dr. Lilly gives us a call this morning. He is currently on his way to Jefferson City to talk about PDMP. 

View the show notes in Google Docs here: http://bit.ly/3bFS43j Gonorrhea Updates Gonorrhea Treatment and Care. Centers for Disease Control and Prevention Website. https://www.cdc.gov/std/gonorrhea/treatment.htm. Published December 14, 2020. Accessed January 11, 2021. CDC No Longer Recommends Oral Drug for Gonorrhea Treatment. Centers for Disease Control and Prevention. https://www.cdc.gov/nchhstp/newsroom/2012/gctx-guidelines-pressrelease.html. Published August 9, 2012. Accessed January 11, 2021. Recurrent UTI Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019). American Urological Association. https://www.auanet.org/guidelines/recurrent-uti?fbclid=IwAR1TwSTQNHv8PDWLfW7WjsDan46D_9b6Qs1ptJxaXr6YFnDpBeptpW3BY. Published 2019. Accessed January 11, 2021. Combo Ibuprofen and Acetaminophen / Pain Advil® Dual Action. GSK Expert Portal. https://www.gskhealthpartner.com/en-us/pain-relief/brands/advil/products/dual-action/?utmsource=google&utmmedium=cpc&utmterm=ibuprofen+acetaminophen&utmcampaign=GS+-+Unbranded+Advil+DA+-+Alone+-+PH. Accessed January 11, 2021. FDA approves GSK's Advil Dual Action with Acetaminophen for over-the-counter use in the United States. GSK. https://www.gsk.com/en-gb/media/press-releases/fda-approves-gsk-s-advil-dual-action-with-acetaminophen-for-over-the-counter-use-in-the-united-states/. Published March 2, 2020. Accessed January 11, 2021. Tanner T, Aspley S, Munn A, Thomas T. The pharmacokinetic profile of a novel fixed-dose combination tablet of ibuprofen and paracetamol. BMC clinical pharmacology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906415/. Published July 5, 2010. Accessed January 11, 2021. Searle S, Muse D, Paluch E, et al. Efficacy and Safety of Single and Multiple Doses of a Fixed-dose Combination of Ibuprofen and Acetaminophen in the Treatment of Postsurgical Dental Pain: Results From 2 Phase 3, Randomized, Parallel-group, Double-blind, Placebo-controlled Studies. The Clinical journal of pain. https://pubmed.ncbi.nlm.nih.gov/32271183/. Published July 2020. Accessed January 11, 2021. 1000 mg versus 600/650 mg Acetaminophen for Pain or Fever: A Review of the Clinical Efficacy. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK373467/. Published June 17, 2016. Accessed January 11, 2021. Motov S. Is There a Limit to the Analgesic Effect of Pain Medications? Medscape. https://www.medscape.com/viewarticle/574279. Published June 17, 2008. Accessed January 11, 2021. Motov, Sergey. Faculty Forum: A Practical Approach to Pain Management. YouTube. https://www.youtube.com/watch?v=lJSioPsGw3A. The Center for Medical Education. Published December 2, 2020. Accessed January 1, 2021. Wuhrman E, Cooney MF. Acute Pain: Assessment and Treatment. Medscape. https://www.medscape.com/viewarticle/735034_4. Published January 3, 2011. Accessed January 11, 2021. Social Pain Dewall CN, Macdonald G, Webster GD, et al. Acetaminophen reduces social pain: behavioral and neural evidence. Psychological science. https://pubmed.ncbi.nlm.nih.gov/20548058/. Published June 14, 2010. Accessed January 11, 2021. Mischkowski D, Crocker J, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Social cognitive and affective neuroscience. https://pubmed.ncbi.nlm.nih.gov/27217114/. Published May 5, 2016. Accessed January 11, 2021. Other / Recurrent liner notes Center for Medical Education. https://courses.ccme.org/. Accessed January 11, 2021. Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed January 11, 2021. The Procedural Pause by James R. Roberts, MD, & Martha Roberts, ACNP, PNP. Emergency Medicine News. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx. Accessed January 11, 2021. The Skeptics' Guide to Emergency Medicine. sgem.ccme.org. https://sgem.ccme.org/. Accessed January 11, 2021. Trivia Question: Send answers to 2viewcast@gmail.com Please note that you must answer the 2 part question to win a copy of the EMRA Pain Guide. “What controversial drug was given a black box warning for prolonged QT and torsades in 2012 and now has been declared by WHICH organization to be an effective and safe treatment use for nausea, vomiting, headache and agitation?” Practical Pain Management in Acute Care Setting Handout Sergey Motov, MD @painfreeED • Pain is one of the most common reasons for patients to visit the emergency department and other acute care settings. Due to the extensive number of visits related to pain, clinicians and midlevel providers should be aware of the various options, both pharmacological and nonpharmacological, available to treat patients with acute pain. • As the death toll from the opioid epidemic continues to grow, the use of opioids in the acute care setting as a first-line treatment for analgesia is becoming increasingly controversial and challenging. • There is a growing body of literature that is advocating for more judicious use of opioids and well as their prescribing and for broader use of non-pharmacological and non-opioid pain management strategies. • The channels/enzymes/receptors targeted analgesia (CERTA) concept is based on our improved understanding of the neurobiological aspect of pain with a shift from a symptom-based approach to pain to a mechanistic approach. This targeted analgesic approach allows for a broader utilization of synergistic combinations of nonopioid analgesia and more refined and judicious (rescue) use of opioids. These synergistic combinations result in greater analgesia, fewer side effects, lesser sedation, and shorter LOS. (Motov et al 2016) General Principles: Management of acute pain in the acute care setting should be patient-centered and pain syndrome-specific by using multimodal approach that include non-pharmacological modalities and pharmacological ones that include non-opioid and opioid analgesics. Assessment of acute pain should be based on a need for analgesics to improve functionality, rather than patients-reported pain scores. Brief pain inventory short form BPI-SF is better than NRS/VAS as it assesses quantitative and qualitative impact of pain (Im et al 2020). ED clinicians should engage patients in shared decision-making about overall treatment goals and expectations, the natural trajectory of the specific painful condition, and analgesic options including short-term and long-term benefits and risks of adverse effects. If acute pain lasting beyond the expected duration, complications of acute pain should be ruled out and transition to non-opioid therapy and non-pharmacological therapy should be attempted. Non-Pharmacologic Therapies • Acute care providers should consider applications of heat or cold as well as specific recommendations regarding activity and exercise. • Music therapy is a useful non-pharmacologic therapy for pain reduction in acute care setting (music-assisted relaxation, therapeutic listening/musical requests, musical diversion, song writing, and therapeutic singing (Mandel 2019). • The use of alternative and complementary therapies, such as acupuncture, guided imagery, cognitive-behavioral therapy, and hypnosis have not been systemically evaluated for use in the Acute care setting including ED. (Dillan 2005, Hoffman 2007) • In general, their application may be limited for a single visit, but continued investigation in their safety and efficacy is strongly encouraged. • Practitioners may also consider utilization of osteopathic manipulation techniques, such as high velocity, low amplitude techniques, muscle energy techniques, and soft tissue techniques for patients presenting to the acute care setting with pain syndromes of skeletal, arthroidal, or myofascial origins. (Eisenhart 2003) Opioids • Acute Care providers are uniquely positioned to combat the opioid epidemic by thoughtful prescribing of parenteral and oral opioids in inpatient setting and upon discharge, and through their engagement with opioid addicted patients in acute care setting. • Acute Care providers should make every effort to utilize non-pharmacological modalities and non-opioid analgesics to alleviate pain, and to use opioid analgesics only when the benefits of opioids are felt to outweigh the risks. (not routinely) • When opioids are used for acute pain, clinicians should combine them with non-pharmacologic and non-opioid pharmacologic therapy: Yoga, exercise, cognitive behavioral therapy, complementary/alternative medical therapies (acupuncture); NSAID's, Acetaminophen, Topical Analgesics, Nerve blocks, etc. • When considering opioids for acute pain, Acute Care providers should involve patients in shared decision-making about analgesic options and opioid alternatives, risks and benefits of opioid therapies, and rational expectations about the pain trajectory and management approach. • When considering opioids for acute pain, acute care providers should counsel patients regarding serious adverse effects such as sedation and respiratory depression, pruritus and constipation, and rapid development of tolerance and hyperalgesia. • When considering administration of opioids for acute pain, acute care providers should make every effort to accesses respective state's Prescription Drug Monitoring Program (PDMP). The data obtained from PDMP's to be used to identify excessive dosages and dangerous combinations, identify and counsel patients with opioid use disorder, offer referral for addiction treatment. • PDMPs can provide clinicians with comprehensive prescribing information to improve clinical decisions around opioids. However, PDMPs vary tremendously in their accessibility and usability in the ED, which limits their effectiveness at the point of care. Problems are complicated by varying state-to-state requirements for data availability and accessibility. Several potential solutions to improving the utility of PDMPs in EDs include integrating PDMPs with electronic health records, implementing unsolicited reporting and prescription context, improving PDMP accessibility, data analytics, and expanding the scope of PDMPs. (Eldert et al, 2018) • Parenteral opioids when used in titratable fashion are effective, safe, and easily reversible analgesics that quickly relieve pain. • Acute care clinicians should consider administering these analgesics for patients in acute pain where the likelihood of analgesic benefit is judged to exceed the likelihood of harm. • Parenteral opioids must be titrated regardless of their initial dosing regimens (weight-based or fixed) until pain is optimized to acceptable level (functionality status) or side effects become intolerable. • When parenteral opioids are used, patients should be engaged in shared-decision making regarding the route of administration, as repetitive attempts of IV cannulation and intramuscular injections are associated with pain. In addition, intramuscular injections are associated with unpredictable absorption rates, and complications such as muscle necrosis, soft tissue infection and the need for dose escalation. (Von Kemp 1989, Yamanaka 1985, Johnson 1976) • Morphine sulfate provides better balance of analgesic efficacy and safety among all parenteral opioids. a. Dosing regimens and routes: b. IV: 0.05-0.1mg/kg to start, titrate q 10-20 min c. IV: 4-6 mg fixed, titrate q 10-20 min d. SQ: 4-6 mg fixed, titrate q 20 min e. Nebulized: 0.2 mg/kg or 10-20 mg fixed, repeat q 15-20 min f. PCA: prone to dosing errors g. IM: should be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) • Hydromorphone should be avoided as a first-line opioid due to significant euphoria and severe respiratory depression requiring naloxone reversal. Due to higher lipophilicity, Hydromorphone use is associated with higher rates of euphoria and subsequent development of addiction. Should hydromorphone be administered in higher than equi-analgesic morphine milligram equivalents, close cardiopulmonary monitoring is strongly recommended. Dosing h. IV: 0.2-0.5 mg initial, titrate q10-15 min i. IM: to be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) j. PCA: prone to dosing errors (severe CNS and respiratory depression) k. Significantly worse AE profile in comparison to Morphine l. Equianalgesic IV conversion (1 mg HM=8mg of MS) m. Overprescribed in >50% of patients n. Inappropriately large dosing in EM literature: 2 mg IVP o. Abuse potential (severely euphoric due to lipophilicity) • Fentanyl is the most potent opioid, short-acting, requires frequent titration. Dosing: p. IV: 0.25-0.5 μg/kg (WB), titrate q10 min q. IV: 25-50 μg (fixed), titrate q10 min r. Nebulization: 2-4 μg/kg, titrate q20-30 min s. IN: 1-2 μg/kg, titrate q5-10min t. Transbuccal: 100-200μg disolvable tablets u. Transmucosal: 15-20 mcg/kg Lollypops • Opioids in Renal Insufficiency/Renal Failure Patients-requires balance of ORAE with pain control by starting with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. (Dean 2004, Wright 2011) • Opioid-induced pruritus is centrally mediated process via μ-opioid receptors as naloxone, nalbuphine reverse it, and can be caused by opioids w/o histamine release (Fentanyl). Use ultra-low-dose naloxone of 0.25 -1 mcg/kg/hr with NNT of 3.5. (Kjellberg 2001) • When intravascular access is unobtainable, acute care clinicians should consider utilization of intranasal (fentanyl), nebulized (fentanyl and morphine), or transmucosal (rapidly dissolvable fentanyl tablets) routes of analgesic administration for patients with acute painful conditions. • Breath actuated nebulizer (BAN): enclosed canister, dual mode: continuous and on-demand, less occupational exposures. a. Fentanyl: 2-4 mcg//kg for children, 4 mcg/kg for adults: titration q 10 min up to three doses via breath-actuated nebulizer (BAN): systemic bioavailability of 50-60% of IV route. (Miner 2007, Furyk 2009, Farahmand 2014) b. Morphine: 10-20 mg g10 min up to 3 doses via breath-actuated nebulizer (BAN)-Systemic bioavailability (concentration) of 30-35% of IV Route. (Fulda 2005, Bounes 2009, Grissa 2015) c. Intranasal Fentanyl: IN via MAD at 1-2 mcg/kg titration q 5 min (use highly concentrated solution of 100mcg/ml for adults and 50 mcg/ml for children)- systemic bioavailability of 90% of IV dosing. (Karisen 2013, Borland 2007, Saunders 2010, Holdgate 2010) d. IN route: shorter time to analgesia, titratable, comparable pain relief to IV route, minimal amount of side effects, similar rates of rescue analgesia, great patients and staff satisfaction. Disadvantages: requires highly concentrated solutions that not readily available in the ED, contraindicated in facial/nasal trauma. Oral Opioids • Oral opioid administration is effective for most patients in the acute care setting, however, there is no appreciable analgesic difference between commonly used opioids (oxycodone, hydrocodone and morphine sulfate immediate release (MSIR). • When oral opioids are used for acute pain, the lowest effective dose and fewest number of tablets needed should be prescribed. In most cases, less than 3 days' worth are necessary, and rarely more than 5 days' worth are needed. • If painful condition outlasts three-day supply, re-evaluation in health-care facility is beneficial. Consider expediting follow-up care if the patient's condition is expected to require more than a three-day supply of opioid analgesics. • Only Immediate release (short-acting) formulary are to be prescribed in the acute care setting and at discharge. • Clinicians should not administer or prescribe long-acting, extended-release, or sustained-release opioid formulations, which include both oral and transdermal (fentanyl) medications in the acute care setting. These formulations are not indicated for acute pain and carry a high risk of overdose, particularly in opioid-naïve patients. • Acute care providers should counsel patients about safe medication storage and disposal, as well as the consequences of failure to do this; potential for abuse and misuse by others (teens and young adults), and potential for overdose and death (children and teens). • Oxycodone is no more effective than other opioids (hydrocodone, MSIR). Oxycodone has highest potential for abuse, misuse and diversion as well as increased risks of overdose, addiction and death. Oxycodone should be avoided as a first-line oral opioid for acute pain. ( Strayer 2016) • If still prescribed, lowest dose (5mg) in combination with acetaminophen (lowest dose of 325 mg) should be considered as it associated with less abuse and diversion (in theory). Potential for acetaminophen overdose exist though with combination. • Hydrocodone is three times more prescribed than oxycodone, but three times less used for non-medical purpose. Combo with APAP (Vicodin)-Use lowest effective dose for hydrocodone and APAP (5/325). (Quinn 1997, Adams 2006) • Immediate release morphine sulfate (MSIR) administration is associated with lesser degree of euphoria and consequently, less abuse potential (Wightman 2012). ED providers should consider prescribing Morphine Sulfate Immediate Release Tablets (MSIR) (Wong 2012, Campos 2014) for acute pain due to: o Similar analgesic efficacy to Oxycodone and Hydrocodone o Less euphoria (less abuse potential) o Less street value (less diversion) o More dysphoria in large doses o Less abuse liability and likeability • Tramadol should not be used in acute care setting and at discharge due to severe risks of adverse effects, drug-drug interactions, and overdose. There is very limited data supporting better analgesic efficacy of tramadol in comparison to placebo, or better analgesia than APAP or Ibuprofen. Tramadol dose not match analgesic efficacy of traditional opioids. (Juurlink 2018, Jasinski 1993, Babalonis 2013) • Side effects are: o Seizures o Hypoglycemia o Hyponatremia o Serotonin syndrome o Abuse and addiction • Codeine and Codeine/APAP is a weak analgesic that provides no better pain relief than placebo. Codeine must not be administered to children due to: o dangers of the polymorphisms of the cytochrome P450 iso-enzyme: o ultra-rapid metabolizers: respiratory depression and death o poor metabolizers: absent or insufficient pain relief • Transmucosal fentanyl (15 and 20 mcg/kg lollypops) has an onset of analgesia in 5 to 15 minutes with a peak effect seen in 15 to 30 minutes (Arthur 2012). • Transbuccal route can be used right at the triage to provide rapid analgesia and as a bridge to intravenous analgesia in acute care setting. (Ashburn 2011). A rapidly dissolving trans-buccal fentanyl (100mcg dose) provides fast pain relief onset (median 10 min), great analgesics efficacy, minimal need for rescue medication and lack of side effects in comparison to oxycodone/acetaminophen tablet (Shear 2010) • Morphine Milligram Equivalent (MME) is a numerical standard against which most opioids can be compared, yielding a comparison of each medication's potency. MME does not give any information of medications efficacy or how well medication works, but it is used to assess comparative potency of other analgesics. • By converting the dose of an opioid to a morphine equivalent dose, a clinician can determine whether a cumulative daily dose of opioids approaches an amount associated with increased risk of overdose and to identify patients who may benefit from closer monitoring, reduction or tapering of opioids, prescribing of naloxone, and other measures to reduce risk of overdose. • Opioid-induced hyperalgesia: o opioid-induced hyperalgesia (OIH) is a rare syndrome of increasing pain, often accompanied by neuroexcitatory effects, in the setting of increasing opioid therapy. o Morphine is by far the most common opiate implicated in OIH. Hydromorphone and oxycodone, members of the same class of opiate as morphine (phenanthrenes), can also cause OIH. Fentanyl, a synthetic opioid in the class of phenylpiperidine, is less likely to precipitate OIH. Existing data suggests that OIH is caused by multiple opioid-induced changes to the central nervous system including: -Activation of N-methyl-D-aspartate (NMDA) receptors -Inhibition of the glutamate transporter system -Increased levels of the pro-nociceptive peptides within the dorsal root ganglia -Activation of descending pain facilitation from the rostral ventromedial medulla -Neuroexcitatory effects provoked by metabolites of morphine and hydromorphone • OIH can be confused with tolerance as in both cases patients report increased pain on opioids. The two conditions can be differentiated based on the patient's response to opioids. In tolerance, the patient's pain will improve with dose escalation. In OIH, pain will worsen with opioid administration. This paradoxical effect is one of the hallmarks of the syndrome. Non-opioid analgesics • Acetaminophen is indicated for management of mild to moderate pain and as a single analgesic and has modest efficacy at most. Addition of Acetaminophen to Ibuprofen does not provide better analgesia for patients with acute low back pain. The greatest limitation to the use of intravenous (IV) versus oral acetaminophen is the nearly 100-fold cost differential, which is likely not justified by any marginal improvement in pain relief. Furthermore, IV APAP provide faster onset of analgesia only after an initial dose. (Yeh 2012, Serinken 2012) • NSAIDs should be administered at their lowest effective analgesic doses both in the ED and upon discharge and should be given for the shortest appropriate treatment course. Caution is strongly advised when NSAIDs are used in patients at risk for renal insufficiency, heart failure, and gastrointestinal hemorrhage, as well as in the elderly. Strong consideration should be given to topical NSAID's in managing as variety of acute and chronic painful Musculo-skeletal syndromes. The analgesic ceiling refers to the dose of a drug beyond which any further dose increase will not result in additional analgesic efficacy. Thus, the analgesics ceiling for ibuprofen is 400 mg per dose (1200 mg/24 h) and for ketorolac is 10 mg per dose (10 mg/24 h). These doses are less than those often prescribed for control of inflammation and fever. When it comes to equipotent doses of different NSAIDs, there is no difference in analgesic efficacy. • Ketamine, at sub-dissociative doses (also known as low-dose ketamine or analgesic dose ketamine) of 0.1 to 0.4 mg/kg, provided effective analgesia as a single agent or as an adjunct to opioids (reducing the need for opioids) in the treatment of acute traumatic and nontraumatic pain in the ED. This effective analgesia, however, must be balanced against high rates of minor adverse side effects (14%–80%), though typically short-lived and not requiring intervention. In addition to IV rout, ketamine can be administered via IN,SQ, and Nebulized route. • Local anesthetics are widely used in the ED for topical, local, regional, intra-articular, and systemic anesthesia and analgesia. Local anesthetics (esters and amides) possess analgesic and anti-hyperalgesic properties by non-competitively blocking neuronal sodium channels. o Topical analgesics containing lidocaine come in patches, ointments, and creams have been used to treat pain from acute sprains, strains, and contusions as well as variety of acute inflammatory and chronic neuropathic conditions, including postherpetic neuralgia (PHN), complex regional pain syndromes (CRPS) and painful diabetic neuropathy (PDN). o UGRA used for patients with lower extremity fractures or dislocations (eg, femoral nerve block, fascia iliaca compartment block) demonstrated significant pain control, decreased need for rescue analgesia, and first-attempt procedural success. In addition, UGRA demonstrated few procedural complications, minimal need for rescue analgesia, and great patient satisfaction. o Analgesic efficacy and safety of IV lidocaine has been evaluated in patients with renal colic and acute lower back pain. Although promising, this therapy will need to be studied in larger populations with underlying cardiac disease before it can be broadly used. o knvlsd • Antidopaminergic and Neuroleptics are frequently used in acute care settings for treatment of migraine headache, chronic abdominal pain, cannabis-induced hyperemesis. • Anti-convulsant (gabapentin and pregabalin) are not recommended for management of acute pain unless pain is of neuropathic origin. Side effects, particularly when combined with opioids (potentiation of euphoria and respiratory depression), titration to effect, and poor patients' compliance are limiting factors to their use. (Peckham 2018) References: Chang HY, Daubresse M, Kruszewski SP, et al. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med 2014;32(5):421–31. Green SM. There is oligo-evidence for oligoanalgesia. Ann Emerg Med 2012;60: 212–4. Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med. 2017 Feb;35(2):337-341. Smith RJ, Rhodes K, Paciotti B, Kelly S,et al. Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic. Ann Emerg Med. 2015 Sep;66(3):246-252 Meisel ZF, Smith RJ. Engaging patients around the risks of opioid misuse in the emergency department. Pain Manag. 2015 Sep;5(5):323-6. Wightman R, Perrone J. (2017). Opioids. In Strayer R, Motov S, Nelson L (Eds.), Management of Pain and Procedural Sedation in Acute Care. http://painandpsa.org/opioids/ Motov S, Nelson L, Advanced Concepts and Controversies in Emergency Department Pain Management. Anesthesiol Clin. 2016 Jun;34(2):271-85. doi: 10.1016/j.anclin.2016.01.006. Ducharme J. Non-opioid pain medications to consider for emergency department patients. Available at: http://www.acepnow.com/article/non-opioid-painmedications- consider-emergency-department-patients/. 2015. Wightman R, Perrone J, Portelli I, et al. Likeability and Abuse Liability of Commonly Prescribed Opioids. J Med Toxicol. September 2012. doi: 10.1007/s12181-012-0263-x Zacny JP, Lichtor SA. Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers. Psychopharmacology (Berl) 2008 Jan;196(1):105–16. Hoppe JA, Nelson LS, Perrone J, Weiner SG, Prescribing Opioids Safely in the Emergency Department (POSED) Study Investigators. Opioid Prescribing in a Cross Section of US Emergency Departments. Ann Emerg Med. 2015;66(3):253–259. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56(1):19–23 Weiner SG, Griggs CA, Mitchell PM, et al. Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department. Ann Emerg Med 2013;62(4):281–9. Greenwood-Ericksen MB, Poon SJ, Nelson LS, Weiner SG, et al. Best Practices for Prescription Drug Monitoring Programs in the Emergency Department Setting: Results of an Expert Panel. Ann Emerg Med. 2016 Jun;67(6):755-764 Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010;44(11):1800–9. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med 2005; 46:362–7. Birnbaum A, Esses D, Bijur PE, et al. Randomized double-blind placebo- controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med. 2007;49(4):445–53. Patanwala AE, Edwards CJ, Stolz L, et al. Should morphine dosing be weight based for analgesia in the emergency department? J Opioid Manag 2012; 8(1):51–5. Lvovschi V, Auburn F, Bonnet P, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med 2008;26:676–82. Chang AK, Bijur PE, Napolitano A, Lupow J, et al. Two milligrams i.v. hydromorphone is efficacious for treating pain but is associated with oxygen desaturation. J Opioid Manag. 2009 Mar-Apr;5(2):75-80. Sutter ME, Wintemute GJ, Clarke SO, et al. The changing use of intravenous opioids in an emergency department. West J Emerg Med 2015;16:1079-83. Miner JR, Kletti C, Herold M, et al. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med 2007;14:895–8. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas 2009;21:203–9. Borland M, Jacobs I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med 2007;49:335–40 Im DD, Jambaulikar GD, Kikut A, Gale J, Weiner SG. Brief Pain Inventory-Short Form: A New Method for Assessing Pain in the Emergency Department. Pain Med. 2020 Sep 11:ppnaa269. doi: 10.1093/pm/pnaa269. Epub ahead of print. PMID: 32918473. Mandel SE, Davis BA, Secic M. Patient Satisfaction and Benefits of Music Therapy Services to Manage Stress and Pain in the Hospital Emergency Department. J Music Ther. 2019 May 10;56(2):149-173. Piatka C, Beckett RD. Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review. Acad Emerg Med. 2020 Feb;27(2):148-160. Tzabazis A, Kori S, Mechanic J, Miller J, Pascual C, Manering N, Carson D, Klukinov M, Spierings E, Jacobs D, Cuellar J, Frey WH 2nd, Hanson L, Angst M, Yeomans DC. Oxytocin and Migraine Headache. Headache. 2017 May;57 Suppl 2:64-75. doi: 10.1111/head.13082. PMID: 28485846. Yeh YC, Reddy P. Clinical and economic evidence for intravenous acetaminophen. Pharmacotherapy 2012;32(6):559–79. Serinken M, Eken C, Turkcuer I, et al. Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blinded controlled trial. Emerg Med J 2012;29(11):902–5. Wright JM, Price SD, Watson WA. NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother 1994;28(3):309–12. Turturro MA, Paris PM, Seaberg DC. Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain. Ann Emerg Med 1995;26(2):117–20. Catapano MS. The analgesic efficacy of ketorolac for acute pain [review]. J Emerg Med 1996;14(1):67–75 Dillard JN, Knapp S. Complementary and alternative pain therapy in the emergency department. Emerg Med Clin North Am 2005; 23:529–549. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26:1–9. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc 2003;103:417–421.

 The sun rises over the San Joaquin Valley, California, today is October 9, 2020. About one year ago, the American Thoracic Society and Infectious Diseases Society of America issued an official clinical practice guideline regarding the diagnosis and treatment of adults with community acquired pneumonia (CAP). There you can find the answer to 16 common questions about CAP in adults. For example, question 8 refers to the antibiotics recommended for empiric treatment of CAP in adults as outpatients. For healthy outpatient adults without comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) or risk factors for antibiotic resistant pathogens (prior respiratory isolation of MRSA or Pseudomonas, or recent hospitalization AND receipt of parenteral antibiotics in the last 90 d), It is recommended monotherapy with amoxicillin or doxycycline or a macrolide.For outpatient adults with comorbidities, the antibiotics recommended (without specific order) are 1. Combination of amoxicillin/clavulanate or cephalosporin (such as Cefuroxime) PLUS Macrolide (such as azithromycin) or doxycycline or2. Monotherapy with respiratory fluoroquinolone (such as levofloxacin).CAP with no comorbidities in adult: Monotherapy with amoxicillin, doxy or a macrolide. CAP with comorbidities: Combined Augmentin or cephalosporin PLUS a macrolide or doxycycline. It’s a tongue twister, may it’s better if you take a look at the official recommendation.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “Courage isn’t having the strength to go on – it is going on when you don’t have strength. – Napoleon Bonaparte.Dr. Arreaza: Courage means to keep going even when you don’t have strength. Feeling discouraged is not uncommon during residency. You may feel inadequate at times, you may feel like “you don’t know enough,” but don’t worry, it is not easy, but the extra work is worth it. Get the courage to keep going. Dr. Patel: Hi listeners, I’d like to introduce myself, name is Ravi Patel, I’m a non-practicing MD who recently moved to Bakersfield and just met Dr. Arreaza, and his quote resonates with me because my journey to practicing medicine has been quite long and I definitely feel the importance in not giving up in the face of discouragement. Dr. Arreaza: Can you tell us a little bit of your background on working with pain management and opioids?Dr. Patel: I have several years of experience working in pain management and primary care with the Vegas metro population, huge indigent population which faces unique challenges especially in regards to opiate therapy. I’m here to discuss with Dr. Arreaza issues involving opiate usage, when it is appropriate, when it is not appropriate, and the importance of limiting usage, and in what cases long term usage is appropriate.Dr. Arreaza: That’s going to be our first topic – opiate therapy. When is it appropriate? How do you screen patients for therapy?Dr. Patel: It’s important to follow CDC guidelines, great place to begin, in screening patients it is inevitable due to the nature of opiates, to have drug-seeking patients. I like to begin with CDC guidelines. It’s important to stay under 90 MMEs per day, just in terms of efficacy and of course legal reasons, and most importantly patient safety. I like to follow the rule of 3 and 7, meaning acute patients, acute care in acute care settings, more so ED settings rather than urgent care, where 3-day courses of opiates are more suitable. Of course, there are other reasons as well, such as peri-surgical pain, 1-2 weeks may be appropriate, and then going case by case basis for chronic opiate therapy. Dr. Arreaza: Acute pain is an indication for opiates, like a fracture, so do you say 2 weeks would be enough?Dr. Patel: Every patient is different, look at it on case by case basis. More so than the number of days it’s the MMEs and the strength of the medication being prescribed. We want to start with longer acting medications; short-term, short acting medications tend to produce that feeling of euphoria, that instant rush that has a psychological addiction factor. I have seen many patients that go in for something as simple as a fracture and come out with an addiction to opiates. It can happen very quickly, in less than a week, in a matter of few days, opiate addiction takes place.Dr. Arreaza: So, we can start an addiction by just prescribing one week of opiates.Dr. Patel: Correct.Dr. Arreaza: Well the symptoms you mentioned, the patients who get this energy bust or euphoria, those are the patients who are more at risk of being addicted, and of course there is a genetic and biological component to it as well. I can tell you by experience that my patients usually say they feel sleepy; it has a sedative effect. Those are usually the lower addiction risk, right? Dr. Patel: Correct.Dr. Arreaza: Well I’m glad to say that one day I took opioids, I had a cornea transplant, I had horrible pain, a leaky eye, and every time I took opioids I fell asleep, it was the only way to mitigate my pain, and it also gave me empathy for patients. I know that there is a big component of genetics, so when they have this euphoria because of opioids and become addicted to opioids, sometimes it’s out of their control, sometimes opioids is something they need to live. It’s described as needing water when you are thirsty. That is the addiction; we had an episode on suboxone with the residents and they explained it very well. So, let’s discuss ways and importance of incorporating multi modal treatment in therapy.Dr. Patel: I find in my experience that is important to limit patient’s expectations of how much pain can be relieved from the get-go. Develop an onboarding plan and discuss what the therapy will entail. Many patients go in with the expectation that opiates are a magic pill that will remove all their pain, which is true, which is responsible for a lot of this addiction as well, but it is important to have an end date, let them know what the maximum you will prescribe, because it is extremely difficult once the patient is in therapy one or two weeks, because they are not often dependent on the opiate, and suddenly you want to take away this magic pill that is making them feel better than they ever have – patients can become aggressive. It’s hard, and plus with this addiction now you have to wean the patient off the medication as well. It’s important to incorporate other treatment modalities as well. I personally think physical therapy is extremely important, and, depending on the nature of the pathology, the nature of the injury, things like epidural injections, steroid injections, things to address the source of the pain over the long term rather than just giving an opiate. An opiate is a blanket you put over the pain, and any kind of pain, it brings it down. But we as providers, we need to focus on the source of the pain, to eliminate or reduce the source of this pain so we can then wean the patient off opiates and they are not dependent on them for the long term.Dr. Arreaza: I had the opportunity to work in a clinic with a patient population who was using a lot of opioids. The provider had prescribed a lot of opioids, and he had left the clinic, so when the patients came to me, they wanted refills, so there was some friction and arguments because I was always concerned about the opioid epidemic. But now that you mention the multi-modal approach, it is probably something I applied without realizing it, incorporating things like gabapentinoids or physical therapy, and then referring a lot of those patients to pain management to get the proper treatment, etc. The way I explained it to my patients is that the opioid will mask the pain, but the pain will always be there, we must address the root of the pain to cure it (if possible).Dr. Patel: As primary care providers, we always see patients who are following up with us, so if they have an acute injury, they go to Urgent Care, they go to the Emergency Room, there are many providers unfortunately who will provide strong opiates to patients. Just as Dr. Arreaza mentioned, like a blanket to reduce all their pain. To get the patient out of the door, especially in larger cities, busier emergency rooms, many times I have seen patients go to the Emergency Room, then see their primary care and they now have an addiction, they want their refill.Dr. Arreaza: So how can we set realistic pain management levels? How can we have that discussion with the patients? Do we agree to a pain level? “Your pain level won't be a 0 it may be a 2”? How do you address that with the patient?Dr. Patel: I think it's important to start a discussion like that by helping the patient realize that pain is a part of life. Most people have some sort of aches and pains, as we get older, part of the aging process, it’s common to have aches and pains and no medication is going to remove 100% of that pain permanently. Having that conversation, make sure the patient understands that the therapy won't be permanent, it won't be chronic. Get the patient used to the idea that they may have to deal with some level of pain in the long term. The patient needs to realize that yes, the opiates will make the pain go away, but when we take you off of it, the pain may come back.Dr. Arreaza: They have to develop some coping mechanisms to deal with pain. There is a lot of evidence that if you practice yoga, you can reduce chronic pain. I have a great experience, I don’t know if it is evidence-based or not, hydrotherapy/water therapy - aquatics, so my patients with fibromyalgia they get a lot of relief with that therapy, and it’s part of that multi modal approach you are suggesting, so think of all different options for patients on opioids, to work on different receptors, different areas, to improve their quality of life.Dr. Patel: Patients with chronic pain will almost always have associated psychiatric issues, so bringing in social workers, psychiatrists, psychologists, someone the patient can speak with. In Vegas like Bakersfield there is a large indigent population, and in my experience, I find more drug seeking behavior in that population. We can help by providing them more resources, allowing their concerns to be heard. They have multiple issues which we may not be aware of, that are causing them to seek these medications, because the whole picture of the patient should be considered.Dr. Arreaza: I'm just thinking right now, even financial reasons, the problem with diversion, the patients could be using the opioid as a way to get some income, so there is a lot of factors implicated in the opioid usage of patients. How do you identify addiction to opioids?Dr. Patel: Well there are the typical signs like you mentioned earlier. The aggressive patient coming in for a follow-up in a primary care clinic looking for a refill on a medication that some doctor somewhere gave them. I think that’s important to be aware of one tool I used where pharmacies report to a central agency so we know if patients are doctor hopping. I’ve caught many patients myself who would visit more than one physician in the same day, and physicians who don’t pay attention to these databases, would refill their prescriptions, and some mentions would get 2-3 different prescriptions in one day and then go around filling them. But in terms of identifying behaviors that are indicative of addiction, patients will have vague complaints, patients who want to come see you once or twice a week, every week attempting to get the medication. Many patients employ different strategies. Patients try to play to your emotions. I would talk about primary care issues, general checkups, blood work, and you'll find that these patients are not interested in anything but getting their medication. Behavior definitely plays a role in identifying addiction patients.Dr. Arreaza: I was looking for the right term, Prescription Drug Monitoring Programs, PDMP. In California, it’s called CURES. We can check CURES for every patient, and now it is required by the DEA, it’s a good tool to have. Also for the residents, you can do a urine drug screening randomly for the patient to see if they are positive for any other illegal drugs or if they are being compliant with the opioids. Dr. Patel: Very important, because there's a lot of comorbid drug use as well. Patients will use opiates as currency to buy other medications, to get illicit drugs, random screening is very important. We would give patients 24 hours to show up, we randomly call them, they have 24 hours to show up with their pills in their pill bottle, we would count them, to verify that they are taking them as prescribed. And anytime you are prescribing any controlled substance, you want to check that database.Dr. Arreaza: People with addiction are not necessarily bad people, some people are regular people addicted to a substance. That’s why we have these programs to help people get those addictions under control. We have some replacements like buprenorphine and suboxone. We will probably have an opportunity to talk about that more in depth later. Let’s talk about the frequent flyers, we have patients who come all the time so what strategies can we use to assist these patients?Dr. Patel: That’s a bit more difficult to deal with because you cannot disregard patients like that. There are patients who have valid concerns that need to be seen frequently, but you develop a sense of judgment about these patients in the sense that, like I mentioned earlier, patient is not concerned about any other issues. They may have an infection or may be limping, but they don’t care at all, they are not interested in multi-modal therapy they just want their prescription and that’s it. It’s an obvious sign of addiction and drug-seeking behavior. Due to laws like ENTALA for example, patients cannot be turned away from the Emergency Room. I have friends in the ED who see the same patient 3 times a week, they come in regularly seeking some kind of medication whether it’s a Toradol shot, or even 1-2 doses of a narcotics. You can’t avoid that, sooner or later we will end up running into those patients, but with patients like that, I always get psychiatry on board to see if there's any underlying factors. Why are they seeking medication attention repeatedly? Is it just drug seeking or are there any other underlying issues? What's going on?Dr. Arreaza: Treating addictions is important but I think we can learn a lot on how to treat pain, as it is the root of the problem here. If you learn how to treat pain we will able to help in this opioid epidemic we are in right now. A reminder to residents; opioid use is linked to obesity as mentioned in a previous episode.Dr. Patel: Another note, as we see more geriatric patients especially in primary care it is a growing problem, opiate usage amongst the elderly because now you have this wonderful drug that makes them feel 20-30 years younger, because who would not want to take that? It’s a tough conversation to have because the elderly patients have valid concerns, growing old is painful, right? At some point, we have to draw a line in the sand, especially with the U.S. using upwards of 80% of the world’s opiate supply, it is unfortunately part of our culture that when something is wrong, something is hurting, we want a pill for that. It is hard to combat, but it is something we have to do every day with our patients.Dr. Arreaza: Maybe next time we can discuss the use of opioids in palliative care.Dr. Patel: Of course, that is a completely valid use Dr. Arreaza: Yea, different topic. Thanks Dr. PatelDr. Patel: Thanks for the opportunity.____________________________Speaking Medical: Hematospermiaby Dr Steven SaitoIn honor of Halloween, we are going to talk blood.  Blood in your ejaculate. Hematospermia is having blood in your semen.  I understand seeing red shoot from your snek is scary, but there are things that the doctor can evaluate you for.  Causes can include: Recent instrumentation. That means events like prostate surgery or a traumatic Foley placement.Infections: both sexual and nonsexual variety Excessive ejaculation particularly if you have been at home during a pandemic with nothing else to do. Cancer: particularly in men over 40 And sporadic: caused by nothing, totally benign.  And it usually resolves with time. After working it up, most commonly reassurance is all that is required for your patients.  So, tell them to suck it up, walk it off, and rub some dirt in it. Remember the medical word of this week, hematospermia. ____________________________Espanish Por Favor: Hongosby Dr Hector ArreazaThe letter H is usually silent in Spanish. So, my name “Hector” is actually pronounced “ek-tor” in English. Among our Spanish’speaking patients is common to hear the word “OS-pit-al” for hospital. Today, I want to teach you the word hongos. Hongos in medical terms refers to fungus or fungal infection. You can add a body part to the words hongos de and get, for example, hongos de las uñas for nail fungus or onychomycosis, hongos de los pies for tinea pedis… they are all hongos. Strangely, hongos is also the word commonly used in Latin America for mushrooms. So, remember the word of this week, hongos, which means fungus.   ____________________________For your Sanity: 789by Dr Tana ParkerWhat do you call a drug addiction counselor addicted to prescription opiates? An Oxymoron.Do you know what 50 did when he got hungry? 58.Have you noticed we don’t have an iPhone 9? Yes, it’s because 789.Of all the inventions in the last 100 years, the whiteboard must be the most remarkable.Conclusion: Now we conclude our episode number 31 “Opioids in Bako.” Talking about opioids is always educational and pertinent. Dr Patel explained the importance of multi-modal treatment of pain, and we discussed different strategies to decrease the use of opioids in our community. Dr Saito explained that hematospermia is the proper way to say bloody semen, a feared symptom in men with a low probability of malignancy, think of infections or trauma before getting into a complicated workup for hematospermia. Dr Arreaza then taught us the Spanish word hongos (pronounced ON-goes, do not pronounce the h) which means fungus. Did you get the joke about 789? You may ask Dr Parker for an explanation.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ravi Patel, Steven Saito, and Tana Parker. Audio edition: Suraj Amrutia. See you next week! _____________________References:American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, 1 October 2019, Pages e45-e67, https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581STPublished: 01 October 2019. Download PDF: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1581STCDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf

The first episode of season two of Healthcare Reimagined was recorded on October 5th, 2020. I had a chance to speak with Meghna Patel, who is the Deputy Secretary for Health Innovation at the Pennsylvania Department of Health. We began with a discussion on Pennsylvania's prescription drug monitoring program, which Meghna and her team launched in a five month time-frame as a means of addressing the growing opioid crisis. The database is available to all licensed prescribers in the state, and in less than four years has grown to serve 110,000 active users on the system. Since the launch of the program, there has been a 35% reduction in opioid prescriptions in the state of Pennsylvania, which is remarkable progress in such a short time.In the second-half of the interview, we discussed COVID Alert PA, which is a contact tracing app released by the state of PA to help support the test-trace-isolate model. The app, created in collaboration with 26 other states and international governments, uses bluetooth technology to create a digital key that allows for anonymous contact tracing. In earlier efforts to contact trace, most people could only identify immediate family members when asked to recall with whom they had been in close contact.  COVID Alert PA uses bluetooth to remove the guesswork, prevent false positives, and has been downloaded  by close to 200,000 people in the first month since it was released. A joint study done by Oxford and Stanford Universities found that if 15% of people in the U.S. downloaded  their state's contact tracing app, we could reduce the spread of the virus by as much as 15%. The Society for HealthCare Innovation is a community of professionals dedicated to improving healthcare through innovation. We are comprised of physicians, nurses, healthcare executives, tech and industry leaders, and many more with a unifying ethos and mission- improving healthcare through innovation.  SHCI Website:  https://www.shci.org/LinkedIn:  https://www.linkedin.com/company/theshci/Spotify:   http://bit.ly/healthcarereimaginedTime Stamps:0:00 -  Introduction 1:18 -  Introduction to PDMP - the PA DOH's prescription drug monitoring program 3:50 -   PDMP's origins span back to the 1970's. It was previously use for law enforcement and investigations, and was never used as clinical tool until it was relaunched in 20164:55 -  How the PA DOH gathers data to measure the impact of the program7:00 -  Outcome improvements that have resulted from the program  8:55 -  PDMP integration into provider EMR's10:25 -  Introduction to COVID Alert PA11:14 -  Apple/Google joint efforts to facilitate contact tracing 11:40 -  The traditional contact tracing strategy and its shortcomings15:00 -  How COVID Alert PA works 18:25 -  It turns out it cannot be used like a dating app (I know, I was also disappointed) 19:08 - How COVID Alert PA is different from traditional contract tracing 20:00 - Adoption rate - 185,000 downloads in the first 30 days since it launched20:50 - International collaboration 24:00 - Important public information about contract tracing apps25:20 - Interoperability and final comments

The argument for keeping State prescription drug monitoring programs and dispelling the myths about interoperability between states and other outdated reasons to enact a federally run PDMP. A conversation with Steve Schierholt, the Executive Director of the Ohio Board of Pharmacy and Jason Slavoski, the PDMP Administrator for the Delaware Division of Professional Regulations. They discuss the states sharing data through Prescription Monitoring Information Exchange or PMIX it's success which dispels one of the myths for the push to have a national database. They also discuss other issues and correct the record about state run PDMP's.

00:00 Missourinet's Brian Hauswirth on PDMP 15:00 Our first drivers test when we were kiids

As tension builds in the Capitol — what pro-business priority bills remain on track with spring break just weeks away? The Missouri Chamber advocacy team discusses movement on legal reform, PDMP, workforce, labor issues and more.

On the latest edition of the Politically Speaking weekly news round-up, St. Louis Public Radio’s team of political reporters talk about efforts in Jefferson City to pass a prescription drug monitoring program — and the reemergence of former Gov. Eric Greitens. St. Louis Public Radio’s Julie O’Donoghue, Jaclyn Driscoll and Jason Rosenbaum discussed how a so-called PDMP once again passed the Missouri House despite loud opposition from some conservative Republicans. It faces a tough reception in the Missouri Senate, where the program aimed at stamping out opioid abuse.

West Virginia continues to lead the nation, and world, in drug overdoses, which makes one ponder as to what is being done at the “ground zero” of the opioid epidemic to save and improve lives. Where else but where it’s “worst” should some of the possible solutions come from? In 2016, an interprofessional panel of experts in pain management—ranging from medicine, osteopathy, nursing, pharmacy, dentistry; public health; the state PDMP; and representatives from insurance providers—was developed with aims of doing just that. The West Virginia Safe & Effective Management of Pain (SEMP) Guidelines were developed to facilitate the shift of the best practices in pain management becoming the new standard of care. SEMP Guidelines include 2 main components including the risk reduction strategy and the clinical treatment algorithms. Pain management algorithms are not available anywhere else in the entire world! So we would like to welcome you to “the West Virginia Way” and see just how the “Wild and Wonderful” state of West Virginia is approaching the opioid epidemic from a true ground zero. After all, if it works where it’s worst, how could it not help your state or your practice? (Recorded at PAINWeek 2018)

In this episode, Jennifer D. Oliva, Associate Professor of Law at Seton Hall University School of Law, discusses her new article “Prescription Drug Policing: The Right to Protected Health Information Privacy Pre- and Post- Carpenter,” forthcoming in the Duke Law Journal. Prof. Oliva begins the discussion explaining how common inaccuracies in understanding the current overdose epidemic (focusing on prescription drug use rather than illicit drug use) exacerbates the crisis. She then explains how this erroneous understanding has precipitated the creation of state prescription drug monitoring programs (PDMPs), which collect and maintain data on every dispensed prescription while collecting massive amounts of protected health information (PHI). Professor Oliva then details how these PDMPs mainly serve as a law enforcement rather than a public health tool, introducing greater amounts of surveillance into the life of the American public. She then discusses search and seizure law under the Fourth Amendment and its applicability to warrantless police seizure of PDMP information while arguing that such searches and seizures are illegal both under pre- and post-Carpenter. She closes by issuing a warning to listeners, urging them to remember how much of their most private information is made public given common technologies. Professor Oliva's scholarship is available on SSRN and she is on Twitter at @jenndoliva.This episode was hosted by Maybell Romero, Assistant Professor of Law at Northern Illinois University College of Law. Romero is on Twitter at @MaybellRomero. See acast.com/privacy for privacy and opt-out information.

Missouri is the only state without a PDMP. They are meant to help fight the opioid crisis, but instead they only infringe upon your liberty and drive people to the black market where they are poisoned by illicit Chinese Fentanyl. If elected, I will work to make sure a PDMP is not implemented in Missouri. --- Support this podcast: https://anchor.fm/chris-burros/support

This week, Eric Bohl and BJ Tanksley update you on the status of MOFB's priority issues in the state legislature. They cover Wind Farm Taxation, Initiative Petition Reform, Redistricting Reform, PDMP opioid addiction prevention legislation, Broadband funding, Transportation funding, Property Rights/Eminent Domain reform for projects like the Grain Belt Express, and the Animal Agriculture county health ordinance bill.

Eric Bohl, Spencer Tuma, and BJ Tanksley review MOFB's Legislative Briefing and Day at the Capitol, plus the latest on China trade talks, the Clean Water Rule, PDMP bill, and Missouri legislature priorities.

Editor Rachael Herndon Dunn, reporter Alisha Shurr, and producer Aaron Basham recap the week before and preview the week ahead, including talks of the DHSS…

Subscribe through iTunes and Google Play. Welcome to this ASCO in Action podcast. This is ASCO's podcast series where we explore policy and practice issues that have an impact on oncologists, the entire cancer care delivery team, and most importantly, the individuals we care for-- people with cancer. My name is Clifford Hudis, and I'm the CEO of ASCO, as well as the host of the ASCO in Action podcast series. For today's podcast, I'm going to give our listeners a quick update on an important announcement from the Centers for Medicare and Medicaid Services. In an August podcast, I outlined the proposed Medicare Physician Fee Schedule and the Quality Payment Program Rule for 2019. This is commonly referred to as the Physician Fee Schedule. Today, I'm going to provide an update on where we are with this for next year. I have to say in passing, it's probably a good day for me not to have a guest, because I'm here with a terrible cold. So what is the 2019 Medicare Physician Fee Schedule? This is a fee schedule which consists of a complete listing of all of the fees that Medicare uses to pay doctors or other providers and suppliers. It's a comprehensive listing of the maximum fees. And it's updated each year and then used to provide reimbursement to physicians and other providers working on a fee-for-service basis. Now at ASCO, we, every year, review this rule very closely. And we try to determine and predict the impact that it will have on our members, and of course, on our patients. There are three provisions in particular that we want to highlight today. The first of these is related to care provided in calendar year 2019. And CMS estimates that there will be, overall, a 1% reimbursement cut for hematology and oncology, as well as radiation oncology specialties. It is important to note, however, that the actual impact on any individual physician or physician practice will depend on their mix of services-- that is, what it is they exactly provide and bill. Now the administration has publicly stated its aim to reduce the growing administrative burden that we've all been noting and complaining about for the last few years. And the second item we want to point out is there is some evidence of their sensitivity to this issue in the 2019 fee schedule. They intend to reduce the documentation required for evaluation and management services, frequently referred to as E/M. What CMS did is finalize provisions that consolidate E/M payments. And ASCO had expressed concerns about this previously, which the agency acknowledged, along with other stakeholders, by revising the proposal. And, if fully implemented, they believe that the impact will be delayed-- that is, it will not impact providers until 2021. But by that time, CMS plans to consolidate what has historically been Levels 2, 3, and 4 into a single billing level, and then to pay for Level 5 E/M services separately. So overall, this represents a simplification. And it fulfills one of their stated aims, again, of reducing some of the administrative burden that practitioners face. Finally, the third area that I want to highlight is a new rule starting in 2019 that refers to the amount of reimbursement you will receive for new Medicare Part B drugs. Currently, those drugs in Part B are reimbursed at wholesale acquisition cost plus 6%. They will, going forward, be reimbursed at wholesale acquisition cost plus 3%. It's critically important to emphasize that this relates only to those new drugs that are introduced into the supply chain this year. This new provision will also apply to drugs that have not yet reported an average sales price. But the point is it will not apply to drugs that have already been in use. So it only applies to new drugs, meaning that its reach is going to be relatively limited. However, what you can imagine going forward with each new year and new drugs being introduced is that the percentage over wholesale acquisition cost will translate into more and more absolute dollars. And therefore, this may be a growing concern for practices. I want to switch our attention and talk about the Quality Payment Program, or QPP. In the final rule, there is an update to QPP for 2019. The final 2019 payment adjustment for Merit-based Incentive Payment System, or MIPS, practices and providers will become plus or minus 7%. And it will have adjustments to maintain budget neutrality, as well as to reward exceptional performance. Other noteworthy changes will include an increase in the MIPS performance threshold from 15 points, which is where we were in 2018, up to 30 points for 2019. CMS also finalized two new optional opioid-related measures that MIPS providers can use to report on under the Promoting Interoperability category. These measures will give providers an opportunity to earn bonus points and therefore potentially boost their overall MIPS score. These are the two measures specifically. One allows for checking a prescription drug monitoring program, or PDMP, prior to submitting an electronic opioid prescription for any individual patient. And the second is an attempt to verify an existing opioid treatment agreement with the patient receiving the prescription. So I hope that this summary of the updates to the Physician Fee Schedule for 2019 is helpful to our listeners. Ultimately, our goal is to make sure that oncologists can provide the right treatment to the right patient at the right time. And we aim to help CMS implement policies that will advance that goal. ASCO will continue to work closely with the administration to ensure that CMS understands the needs of the oncology community and the full impact that the rule is likely to have. I would encourage you, if you need more information on the Medicare Physician Reimbursement Plan for 2019, to visit ASCO in Action's website. That's at ASCO.org/ASCOaction. And ASCOaction is written as one word. We have a link to the final rule there. And we also have a helpful, I think, webinar that explains the final rule schedule and QPP rule in greater detail. So hoping this is helpful. Until next time, I want to thank you all for listening to this ASCO in Action podcast and hope you don't catch my cold.

Physicians everywhere are required to check state databases when prescribing prescription drugs to their patients. But until now there has been no easy way for them to check databases from other states. That's why Deborah Wade and others at eClinicalWorks, in association with APPRISS Health, are building a Prescription Drug Monitoring Program integration that will make such checks as easy as clicking a button — leading to better and safer medicine across the nation.

The MACo Legislative Committee formally adopted a statement this week to express its views on broad-based tax reform proposals pending before the General Assembly, designed to react (in various ways) to the recently enacted federal tax reforms. Absent state action, some Maryland taxpayers would see an increase in their state and county tax liability — the potential means to offset these changes sit before the legislature in multiple variations of changes to deductions, exemptions, rates, and brackets — each with distinct distributional effects. Governor Larry Hogan this week announced a “lockbox” proposal to ensure that taxes on casino revenues set aside for education are used to supplement, not supplant state funding for public schools. Last month, legislature leadership announced a plan to place a constitutional amendment on the November ballot. The ballot question would ask voters to approve of putting a “lockbox” on casino money (around $500M per year), requiring it to be used for education above the amount set by state formulas. The Governor’s proposal would not require a referendum, it would be done through statute. The House Economic Matters Committee voted down SB 304, Maryland Healthy Working Families Act – Enforcement – Delayed Implementation, which would have delayed implementation of the Maryland Healthy Working Families Act until July 1. The vote was 12-11. The focus now turns to a new wave of employer mandate proposals. A proposal to strengthen Maryland’s Prescription Drug Monitoring Program is likely to spur a debate over who should have access to the database and under what circumstances. As heroin and opioid deaths continue to skyrocket in Maryland, County Health Officers could play a vital role in sharing vital information and best practices with identified prescribers, and increase awareness and improve intervention efforts in cases of patients who may be doctor shopping. On the latest episode of the Conduit Street Podcast, Kevin Kinnally and Michael Sanderson break down MACo’s position on broad-based tax reform proposals, discuss the competing education “lockbox” initiatives, examine employer mandate proposals, preview the looming debate on Maryland’s PDMP, and more!

RACTICE RECOMMENDATIONS 1. Opioids are inherently dangerous, highly addictive drugs with significant abuse potential, numerous side effects, lethality in overdose, rapid development of tolerance, and debilitating withdrawal symptoms. They should be avoided whenever possible and, in most cases, initiated only after other modalities of pain control have been trialed. 2. Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for abuse, addiction, or adverse reactions. 3. Emergency physicians should frequently consult Colorado’s prescription drug monitoring program (PDMP) to assess a patient’s history of prescription drug abuse, misuse, or diversion. 4. Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid prescribing patterns with their clinicians to decrease protocol variabilities. 5. Strongly consider removing prepopulated doses of opioids from order sets in computerized provider order entry (CPOE) systems. 6. Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed. 7. Potential drug interactions must be evaluated, and opioids should be avoided in patients already taking benzodiazepines, barbiturates, or other narcotics. 8. Patients with chronic pain should receive opioid medications from one practice, preferably their primary care provider or pain specialist. Opioids should be avoided in the emergency department treatment of most chronic conditions. Emergency physicians should coordinate care with a patient’s primary care or pain specialist whenever possible, and previous patient-physician contracts regarding opioid use should be honored. 9. Clinicians should abstain from adjusting opioid dosing regimens for chronic conditions and avoid routinely prescribing opioids for acute exacerbations of chronic noncancer pain. 10. “Long-acting” or “extended-release” opioid products should be avoided for the relief of acute pain. 11. Patients receiving controlled medication prescriptions should be able to verify their identity. 12. Patients who receive opioids should be educated about their side effects and potential for addiction, particularly when being discharged with an opioid prescription. 13. When considering opioids, clinicians should prescribe the lowest possible effective dose in the shortest appropriate duration (eg,

Midweek update on the last week of session featuring: PDMP, circuit breaker, and REAL ID. It gets a little emotional at the end, and we wouldn't have it any other way.

This week delves into the budget and public defender funding, PDMP, and Medicaid expansion.