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New Rules For Acute Pain Prescribing in Ohio

A few hours ago, the State Medical Board of Ohio announced new prescribing rules for opioid pain medications in the treatment of acute pain. These rules will take effect beginning on August 31, 2017. These new rules do not apply to the treatment of chronic pain.

Rules for prescribing for acute pain:

  • No more than seven days of opioids can be prescribed to adults
  • No more than five days of opioids can be prescribed to minors, unless written permission from parent/guardian
  • Can prescribe beyond day supply limits only if documented in medical record
  • Total morphine equivalent dose (MED) cannot exceed 30 MED per day
  • New rules do not apply to opioids prescribed for cancer care, palliative care, and hospice care

The State of Ohio Board of Pharmacy has a table of MED doses at this link. I also encourage you to check out the State Medical Board of Ohio links to Acute Pain Rules: Definitions, General Provisions, Prescribing of opioid analgesics for acute pain.

What does this mean? I know our "friends in Columbus" want physicians to write less opioid medication, but this is not the way to do it. Family Physicians like me will be more scared to write for opioid medications for my patients who will need it. Will I have to bring back my patients every seven days? According to the State Medical Board, when does acute pain transition to chronic pain?

In my opinion, these new rules will not help the opioid problem in Ohio. The unintended consequence will be that it will worsen the problem. Back in the 1990s, physicians were forced to address "Pain As The Fifth Vital Sign," which forced physicians to prescribe more opioid medication. Now, with the current opioid crisis, we are being legislated to write less. Will this drive patients to obtaining illegal opioids? The answer is yes, because you see it in the news everyday, especially here in Ohio.

What's the answer to the opioid problem in Ohio and across the country? I know it's complicated, but blaming doctors and putting more restrictions on physicians may get you some political points and help get/keep you elected. Meanwhile, according to the Columbus Dispatch, 4149 Ohioans died from unintentional drug overdoses in 2016, which is a 36 percent leap from the previous year. Plus, 2017 is on track to outpace last year's numbers. When are Ohioans themselves going to stand up and say that enough is enough?

Concussions & CTE

This week, many schools around the state will be getting back to school, and this ultimately means the beginning of high school football season. Through the summer, I've been performing a lot of sports physicals and back to school physicals, and an important topic that I bring up is concussions.

According to our friends at FamilyDoctor.org, a concussion is a type of Traumatic Brain Injury which is defined as a sudden damage to your head. Many associate football with concussions, but other sports including soccer, can also result in concussions. And, the Ohio High School Athletic Association has rules for athletes determined to have concussions.

Signs and Symptoms of Concussion:

  • Loss Of Consciousness
  • Headache
  • Confusion or Memory Problems
  • Dizziness or Balance Problems

OHSAA Rules For Athletes With Concussions:

  • Unable to return to play the same day, under no circumstances
  • For return to play, required to have written authorization from a physician (MD or DO) or certified athletic trainer

There has been a lot in the press about CTE, or Chronic Traumatic Encephalopathy. Symptoms generally appear 8-10 years after an athlete experiences repeated concussions. It is generally believed that CTE occurs in four stages.

Stages of CTE: Chronic Traumatic Encephalopathy

  • Stage 1: Disorientation, dizziness, headaches
  • Stage 2: Memory loss, erratic behavior, poor judgement
  • Stage 3/4: Dementia, movement disorders, tremors, suicidality

Back to school is always an exciting time. But, as school sports progresses, make sure your review the signs and symptoms of concussion. And, as always, if any questions, please reach out to your Family Physician.

Ohio Issue 2: Drug Price Relief Act

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I've been getting a lot of questions from my patients on Ohio Issue 2, the Drug Price Relief Act. Many believe this November 7th ballot issue will be the most expensive in Ohio history. All Ohioans have been seeing the television ads for the past few months. And, each side is accusing the other of deceptive advertising. 

What does Issue 2 say? Issue 2 would require the state of Ohio to pay the same, or lower prices for prescription drugs as the VA (meaning the US Department of Veterans Affairs).

Why is Issue 2 controversial? It's controversial because the voters in Ohio are confused about what actually will happen if Issue 2 passes. Will it actually lower drug prices? This is a key point that cannot ultimately be answered. In the research I have done, experts state that "there are too many variables" in play to predict whether drug prices will actually decrease.

My Bottom Line: I encourage you to check out the websites and videos below and make your own determination. For me, I still have many questions about Issue 2, and I'm not convinced that Issue 2 will lower the price of drugs for my patients. I am going to be voting No on Issue 2. 

Resources for you to read and to view on Ohio Issue 2:

Disclaimer: This essay is my personal and individual opinion, and does not necessarily represent the places I work or the organizations of which I am a member.

Back To School Immunizations

As summer is quickly coming to a close for kids, it's that time of year again to think about Back-To-School. In addition to thinking about school supplies and school clothes, something else to ask yourself is this, "Is my child up to date on immunizations?"

There are certain immunizations that are required to attend school in the states of Ohio and Pennsylvania, and the Ohio Department of Health and Pennsylvania Department of Health have great links to let you know which immunizations are required to attend school. The full immunization schedule can be found at the site for the Centers for Disease Control and Prevention. 

But, in general, the immunizations that my patients and their parents are asking about are the following Back-To-School Immunizations:

  • Before Kindergarten: MMR, Chicken Pox, Polio, Tetanus
  • Before 7th Grade: Tetanus Booster, First Meningitis Shot
  • Before 12th Grade: Second Meningitis Shot

The vaccine against Human Papillomavirus (HPV) is not required to attend school (yet), but I still try to have a discussion with parents about the benefits of this vaccine. And, of course, I do recommend the Flu Shot yearly. 

I also get questions about vaccine exemptions. In the states of Ohio and Pennsylvania (and other states), a child who attends public school can be exempted from taking vaccines in school for medical, religious, and philosophical reasons as long as the parent/guardian provides the school with a written statement along with a waiver form.

This exemption also comes with one caveat: If this school has an outbreak, the school may prevent the child from attending, to protect the health of all students and the faculty.

Of course, I advocate for vaccination, because we have seen the complications of not vaccinating. Remember the 2014 mumps outbreak at Ohio State University? This affected almost 500 people. How about the 2014 measles outbreak at Disneyland in California? I believe these came about because the people affected, for whatever reason, were unvaccinated.

Bottom Line: Vaccines work. Get your children vaccinated. Stay up to date on your (adult) vaccinations. And, finally, visit your Family Doctor to see which vaccines are appropriate for you and your child.

Summer Safety Tips

With the first day of summer a few days ago, summer is now in full swing! I've been getting a lot of questions from parents on the topics of pool safety and fireworks safety. And, I'll focus on those topics in this blog post.

Pool Safety: According to the Centers for Disease Control and Prevention, from 2005-14, there were an average of 3500 fatal unintentional drownings annually, which is about 10 deaths per day. And, approximately one in five of these fatalities were children 14 years old and younger.

Here are three Pool Safety Tips to keep in mind this summer:

  • Never leave a child unattended near water
  • Keep a Life-Saving ring and CPR instructions at poolside
  • Keep a phone at poolside so you can call for help if needed

Fireworks Safety: With July 4th right around the corner, here are a couple of alarming statistics to keep in mind. In a 2014 report by the Consumer Product Safety Commission, 35 percent of people seen in the ER around the time of July 4th were younger than 15 years old. In addition, 28% percent of ER visits were due to sparklers. In case you didn't know, sparklers can reach 1200 degrees F.

Here are three Fireworks Safety Tips to keep in mind:

  • A responsible adult should supervise all firework activities. Never give fireworks to children
  • Always have a bucket of water nearby
  • Never, ever relight a "Dud" firework

I also encourage you to check out the story on the WKBN site called "Tips To Say Safe Around Water, Fireworks as Summer Season Begins." 

'13 Reasons Why' Raises Discussion On Teen Suicide

The Netflix drama "13 Reasons Why" is causing a lot of discussion and controversy on the topic of teen suicide. The show, based on a 2007 young adult novel, tells the story, through the tapes she made, of a high school sophomore who committed suicide. Each tape addresses one of the 13 people the student claims contributed to her death.

Before I go further, I wanted to post the link to the National Suicide Prevention Lifeline and their phone number is 800-273-8255. For those who would rather text, contact the Crisis Text Line by sending "Hello" to 741-741. From a medical standpoint, Family Doctor.org has some useful information to increase awareness about teen depression, cyberbullying, and teen suicide. I also share an NPR audio podcast from May 18, 2017 below, and a video podcast from a Suicide Prevention Social Media community.

Even though that it is powerful storytelling, I would NOT recommend that teenagers watch this show alone. However, I realize a lot of kids watching this on their phones on the bus. So, kids who watch this show need to talk with their parents, or guardians, or school counselors, or other adults where they process what they're seeing and what they're feeling.

No, I do not think this show will cause teens to consider suicide. However, I think that this show is high risk to trigger those teens struggling with mental illness, or those who are/have been affected by bullying/cyberbullying and sexual assault in the past. It is unfortunate that the program did not originally share information about the National Suicide Prevention Hotline or the Crisis Text Line as above. More information was added at the beginning of this month.

To help raise awareness, and to help you, here are my "13 Reasons" to look out for in teens (and adults) as Warning Signs For Suicide:

  • Talking about death and/or suicide in a casual way
  • Saying they wish they hadn't been born
  • Asking about death or how to commit violent acts
  • Talking about leaving or going away
  • Saying they won't need things soon
  • Not wanting to be around people anymore
  • Seeming sad and remote, instead of happy and social
  • Becoming more angry or edgy
  • Losing interest in hobbies or events
  • Having trouble focusing
  • Showing changes in normal routine, such as sleeping, eating, or grooming
  • Acting out in harmful ways like drinking, using drugs, or hurting themselves
  • Getting in trouble with the law

Addendum: I also invite you to check out the WKBN-TV article, "Local doctor discusses Netflix teenage-suicide show '13 Reasons Why'"

Qliance Closes: Is Direct Primary Care Doomed?

Qliance, a shining example of success in the Direct Primary Care movement, closed this week according to The Seattle Times. For those who are not familiar, Direct Primary Care is a newer way to deliver healthcare in which patients pay a monthly fee directly to their doctor, and the doctor's office does not accept insurance plans. There are some exceptions to this, but this his the basic concept.

Over the past 10 years, the Qliance model has been held up as THE model to replicate across the country. Now, it's closed. Over the past 24 hours, there has been a lot of talk on social media about why this happened to Qliance. But, it also begs the question: How does this affect the entire Direct Primary Care movement? Is DPC doomed to fail?

Now, I don't believe that, but it makes a good headline (hehe). Has my friend and DPC advocate, Dr. Ryan Neuhofel said on twitter, "Did the failure of MySpace mean the concept of 'social media' was invalid?" Other people on social media are now saying that at the end, Qliance was not really a Direct Primary Care model.

It will be interesting how the Direct Primary Care community spins the closing of Qliance on social media. What lessons will be learned from the Qliance experience? As far as the movement of Direct Primary Care itself, I'm still inspired by the 2013 words of Dr. Erika Bliss, Qliance CEO, "If Primary Care can't step up right now and own the health care system and change it on behalf of our patients, then we should just go home."

RIP Qliance. Thanks for being a pioneer in the Direct Primary Care Movement....

Why Family Medicine Matters and Previewing #StayWellSoon

Our colleague, Dr. Wanda Filer, Board Chair of the American Academy of Family Physicians, was a guest on the ZDoggMD Facebook Live session yesterday talking about the importance of Family Medicine and the importance of Family Physicians. Why does Family Medicine matter? This brief 20 minute program will tell you why #HealthIsPrimary and HealthIsPrimary.org.

In addition, Dr. Filer and ZDoggMD previewed the #StayWellSoon advocacy and educational campaign that will launch on May 23 at Family Doctor.org. As ZDoggMD says, May 23 will be a Call of Action in which there will be "cards" that will be available not only promoting Family Medicine, but encouraging people to get connected with a Family Physician. More information soon at FamilyDoctor.org

Distracted Driving Is Very Dangerous

Distracted driving is any activity that diverts attention from driving, including talking or texting on your phone, eating and drinking, talking to people in your vehicle, flddling with the radio, entertainment or navigation system - anything that takes attention away from safe driving.

April is Distracted Driving Awareness Month. I get questions all the time from parents worried about their kids, from kids worried about their parents, and everyone else. Distraction is not only dangerous, but it can also be deadly. Here are some 2015 statistics involving distracted drivers from the National Highway Traffic Safety Administration:

  • 3477 people were killed during distracted driving
  • 391,000 people were injured during distracted driving
  • 660,000 drivers are using cell phones while driving

The National Safety Council lists these Five Myths about Distracted Driving in this informative Infographic below:

  • Myth #1: Drivers Can Multitask -> Reality: You cannot totally focus on talking on the phone and safely driving. Trying to do both slows reaction time
  • Myth #2: Talking on a Cell Phone Is Just Like Speaking to a Passenger -> Reality: People in the car can help alert the driver to traffic problems. Those on a cell phone cannot.
  • Myth #3: Speaking Hands-Free Is Safe To Use While Driving -> Reality: Drivers on cell phones can miss seeing up to 50% of their driving environment including pedestrians and red lights
  • Myth #4: I Only Use My Phone At Stop Lights So It's Ok -> Reality: You're still distracted. In a recent study by AAA, people are distracted 27 seconds after they finish sending a voice text.
  • Myth #5: Voice-To-Text is Safe To Do While Driving -> Reality: Actually it's not. If thinking and sending the text is not distracting enough, the autocorrect (or lack of it) will drive you nuts!

With May's upcoming Graduation and Prom season quickly coming upon us, you need to know the facts about distracted driving. If you want more information, check out the National Highway Traffic Safety Administration, the National Safety Council, and the Distracted Driving Awareness month website.

NEOMED Social Media Talk 2017

I'm honored to be a guest of the medical student organization Physicians for Social Responsibility at the Northeast Ohio Medical University. I'll be giving a talk at the university on March 22, 2017. The slides I'll be using are below. I'll be posting more following the talk. If the embed doesn't work below, then click on my slideshare account right here.