Alabama Pain Management Act

 

By: Ty Thomas, MD

It’s here.  House Bill 151 was passed by the House of Representatives April 9, 2013 and the Senate May 2, 2013.  The bill was then quickly signed by Governor Bentley on May 8, 2013.  Officially, the bill will begin implementation January 1^st, 2014.  HB 151 is a 17 page bill which sets the framework for the Alabama Board of Medical Examiners to develop rules and regulations regarding pain management.

The intent of this bill is to address the problem of “diversion, abuse, and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act.”  The first steps outlined in this bill to accomplish its intent is to “require registration of all physicians providing pain management services and to regulate these registrants.”  Pain management services are defined as “those services that involve the prescription of controlled substances in order to treat chronic nonmalignant pain.”    Registration involves a detailed application which includes listing of all other registrants, owners, co-owners, and operators at each practice location.  In addition, a thorough clinical and criminal background check including finger print submission is required.  All costs, in addition to the application fee which is $300, associated with the registration process (i.e., background checks, finger print sets) are borne by the applicant. 

Each location must have a qualified Medical Director.  There are many listed requirements on pages 12 and 13. 

If the Board finds “danger to the public which requires emergency suspension of a registration, it may proceed without hearing effective immediately.”    However, this suspension is to last no more than 120 days during which a formal suspension or proceeding will take place.  The Board may investigate “on its own motion or in response to a written complaint.”  Currently, this isn’t any different to what happens today.  The difference is the fines imposed for failing to register, which are pretty steep, at $10,000 per violation. 

The rules have not yet been publically released by the Board.  The rules will be published for public comment before they are finalized. 

Bottom line:  If you prescribe controlled medications to the chronic pain patient, you need to declare yourself and register.  If you are like most and provide controlled medications for acute pain, then you are not affected by this legislation. 

Alabama Pain Physicians http://bamapain.com/ 

Why a Partial Hospitalization Program (PHP) is Beneficial for Psychiatric Patients

 

By Dr. D. Shawn Harvey, M.D.

Many health care providers are unaware of a growing form of mental health treatment through a partial hospitalization program (PHP). Its popularity stems largely from its cost-effectiveness and accessibility for patients. PHP is for medically stable patients who do not require an inpatient stay, but may benefit from more intensive, daily therapy. Patients also benefit from returning home in the evenings and maintaining important connections to family, friends and the community. I’m able to meet with PHP patients regularly to assess how well they are responding to therapy and adjust medication if needed.

Our treatment team at Brookwood Medical Center’s PHP uses multiple treatment modalities such as, Cognitive Behavioral Therapy, Dialectical Behavior Therapy and Expressive Therapy. The group therapies are a mix of process-oriented, talk therapy and education. The patients have an opportunity to address deeper issues and practice new ways of coping in a safe and supportive environment. 

One of the most beneficial aspects of our program is teaching the practice of mindfulness. Every morning, the patients begin the day by practicing some form of it. Mindfulness teaches patients how to change their relationship to their thinking and brings someone into the present with heightened awareness and focus. Practicing mindfulness has been shown to reduce symptoms of depression and decrease the risk of future relapses.

Brookwood Medical Center’s PHP is called the Inner Path and is located on the hospital’s main campus. It’s a short-term, outpatient program lasting up to two to three weeks, providing treatment for adults experiencing issues that interfere with their ability to function on a daily basis. Many of the patients we see are seeking better ways to cope with mood disorders such as major depression, anxiety, panic and bipolar. Other issues addressed include:  grief and loss, trauma, chronic pain, life transitions and adjustment, work-related stress and relationship conflicts. Our program is not a treatment for substance abuse; however, some of the patients may have a history of alcohol or drug dependence. 

Admission Criteria for InnerPath Patients:

·         Patients must be 19 years of age or older

·         Dealing with ongoing mental health issues such as depression, anxiety or panic

·         Medically stable and cleared for ambulatory care level

·         Psychiatrically stable and able to maintain safety in an unlocked setting

·         Able to hold and self-administer medication, handle self-care and function independently

·         Cognitively capable of participating in and benefitting from intensive group therapy sessions daily

·         Clean and sober and actively engaged in recovery through 12-step or recovery groups

Any health care provider may make a referral and in some cases, the patient may refer him- or herself.  If you would like to make a referral to The Inner Path, download the referral form at bwmc.com/psychiatry. 

Dr. Shawn Harvey is a board-certified psychiatrist and medical director of Brookwood Medical Center’s Partial Hospitalization Program. 

Dry Winter Skin- Tips to help keep your skin moisturized

By: Dr. Zoey Glick

Xerotic (dry) skin is a problem both due to internal causes (i.e. eczema, hypothyroidism, and natural aging) and external causes (i.e. low humidity, dry air, frequent bathing and excessive soap).  The stratum corneum (top layer of the epidermis- the outermost later of skin) is the front line barrier between the environment and the body.  Many authors compare the stratum corneum to a “brick wall.” The “bricks” are the skin cells of the epidermis (corneocytes) and the “mortar” are the extracellular lipids that functions as a glue to keep this barrier intact. The stratum corneum helps detect and regulate if the skin feels moisturized or dry.  Often dry skin can become itchy and patients can develop an “itch scratch cycle” that can be tough to break.   

            During the winter months, here are some helpful tips to keep your skin from becoming dry and itchy.

·         Avoid hot showers

• Avoid topical alcohol, lidocaine, Benadryl, calamine lotion and witch hazel on the skin.  Instead try topical ammonium lactate 12% for dry skin or oral Benadryl for itchy skin.
• Use unscented soaps
• Use soap sparingly and try to concentrate in areas that get “dirtier” (i.e. armpits and groin creases).  Soap can further dry out already xerotic skin!
• The “vehicle” (the ingredient of the moisturizer or topical medicine that gives it its consistency) can impact how well the moisturizer or medicine penetrates the skin.  The thicker the emollient/moisturizer you can tolerate the better. Creams are better than lotions and ointments are the best (if you can stand the grease)!
• Try to minimize the perfumes coming into contact with your skin (i.e. spray your perfume on clothes instead on directly on the skin).
• Use detergents, fabric softeners, and dryer sheets that are fragrance and dye free
• Humidifiers can help combat dry winter air
• Let your physician know exactly what you are using on your skin.  Even if a topical product is not the underlying cause of your skin problems it can exacerbate dry and itchy skin

 

Most importantly, sometimes dry skin will not respond to over the counter treatments and may require a visit to a physician for further evaluation and treatment.  Topical medications and oral medications can be prescribed to help with xerosis and itching.

 

References:

Bolognia JL, Jorizzo JL and Schaffer JV. Dermatology.   Elsevier, 2012. 

Lebwohl MG, Heymann WR, Berth-Jones J and Coulson I.  Treatment of skin disease: Comprehensive Therapeutic Strategies.  Elsevier, 2010.

Dr. Zoey Glick, Total Skin and Beauty Dermatology Center

Children’s of Alabama educators shorten hospital stays for newly diagnosed diabetes patients

 

By: Dr. Mary Lauren Scott

In the recent past, children who were newly diagnosed with diabetes immediately faced a hospitalization that lasted five days. Most of that time was spent teaching parents and their child about the disease and essential care. Over the past decade, Children’s of Alabama has shortened that stay to about two days, while providing better targeted education and follow up.

For instance, I was diagnosed with Type 1 diabetes in the 1990s, at age 12. I was admitted to a general hospital where I stayed for five days in a children’s wing. I wasn’t sick enough to actually need a hospitalization, and I spent my time going to classes with adults who had been recently diagnosed with Type 2 diabetes. So the diabetes education I received wasn’t specific to my condition or my age. Educators at the hospital did teach my parents how to give me insulin injections—the key to treatment of Type 1 diabetes. However, my father was a doctor, and the injections weren’t a big issue for our family.

These days, a newly diagnosed patient is usually hospitalized at Children’s for two days. We have been able to shorten the length of hospitalization for most of our patients by personalizing care and education.

We can focus our efforts on Type 1, Type 2 or even steroid-induced diabetes.  In addition to one-on-one attention, our educators supply families with a plethora of education materials in a folder so they have everything in writing when they go home. Families are plugged into our FAX and email systems so they can easily contact a doctor or educator, and respond appropriately to emergencies.

We follow up with a phone call one to two days after discharge to ensure that everything is OK. We have the families provide us with blood sugar levels three or four days after the child goes home. And the family returns for a follow-up visit and refresher class about one month after discharge.

There are plenty of reasons for this drive for efficiency. First of all, we hope our system is delivering better care for patients. But we are also facing rising rates of Type 1 and Type 2 diabetes in children, particularly in the South. That means we have to care for more patients. In addition, there are not nearly enough pediatric endocrinologists, particularly in the South.

We are also working on ways to improve the transition of patients from pediatric to adult care. The adult medical care system requires that patients take more responsibility for their care. For example, adult patients must understand insurance coverage, how to get prescriptions filled and how to find a primary care doctor.

Our educators have created a program for patients who appear to be ready to move out of pediatric care and into adult care. This often happens when our patients go away to college. In preparation to this move, an educator will meet with a patient at least twice, and a social worker will meet with them at least once. A physician will meet with the patient once or twice to ensure the patient knows how to take their medications and has lined up a physician who treats adults. If the patient is a young lady, we explain to her how a pregnancy could affect their diabetic care.

Recently, the Alabama Department of Motor Vehicle Division/Registration Section approved a license plate to help raise funds for our transitional program. The Hope for Kids with Diabetes tag costs $50, with $41.25 of every purchase benefitting Pediatric Endocrinology at Children’s of Alabama. In addition to the transitional program, the money will be used for other patient care, physician training and research.

Here are some good sources for more information about diabetes and children:

--National Diabetes Education Program at www.YouDiabetesInfo.org.

--American Association of Diabetes Educators at www.diabeteseducator.org.

--American Diabetes Association at www.diabetes.org/planetD.

--American Dietetic Association at www.eatright.org.

--Bam! Body and Mind at www.bam.gov.

--Children With Diabetes at www.childrenwithdiabetes.com.

--And the Juvenile Diabetes Research Foundation at www.jdrf.org.

Dr. Mary Lauren Scott is a pediatric endocrinologist at Children’s of Alabama and an Assistant Professor of Pediatric Endocrinology at UAB

Testing and Preventing Cervical Cancer

By Jessica Gill, MD  at UAB West

Being a woman isn’t easy. Any woman will tell you that. And with all the things that we deal with as we develop, it’s important to be aware of what we need to do to best care for our bodies and our health. We just recently had national breast cancer awareness month, but there’s another cancer that women should dedicate more attention to.

Cervical cancer.

Cervical cancer is when irregular cells on the cervix grow at a dangerous rate. The cervix is the lower part of the uterus that opens into the vagina. Most of the time, cervical cancer is caused by the human papillomavirus - you’ve probably heard it as HPV. HPV can live in your body for years without you realizing it. That’s why it is so important to regularly see your gynecologist and have a Pap smear exams performed.

A lot of people get turned off by the idea of a Pap smear, but two things on that: 1) it is not that bad, and 2) it is too important for your health to go without.

What happens with a Pap smear exam is that while you are on a table your feet are placed in stirrups, and a doctor or nurse places an instrument (a speculum) into your vagina to slightly open it. Cells are then gently scraped from the cervix area and sent to the lab.

No, it’s not the most comfortable thing in the world, but don’t be frightened by the ‘vision’ of it. The doctor and their team are highly trained and work to make it a comfortable environment for the patient.

A woman should begin having Pap smears at age 21, then every three years after, provided that there are no abnormal results. For the most part, cervical cancers develop slowly, and that time frame allows for enough time to make early detections.

While it does not need to replace the need for regular Pap smear tests, there is an HPV vaccine that can be administered to help offer protection from HPV.

It is series of three shots administered over a six month period, and is recommended to be given as early as 11 or 12 years of age. It is important to note that HPV vaccines are currently not recommended for adults older than 26.

The safety and effectiveness for those above that age has not yet been determined. The key here is to reduce your risk of cervical cancer, and the HPV vaccine in addition to regular Pap smear testing can do that.

Don’t avoid your gynecologist - remember, all the other girls have to see them, too. Stay on a regular routine with your testing, and realize that being a woman is a beautiful thing.

Best, Jessica Gill, MD - 
for more information contact _ http://www.medicalwesthospital.org/index.php

Questions, Answers and Encouragement about PCOS

 

By: ART Fertility Program: Drs. Honea, Houserman, Long and Allemand

 

PCOS is a common diagnosis among women, but one that can be filled with misinformation and discouragement.  The ART Fertility Specialists help us understand PCOS, what it means to a fertility diagnosis, and why there are plenty of reasons to be optimistic about successful pregnancy after a PCOS diagnosis.

 

 

What is PCOS?

PCOS stands for polycystic ovary syndrome, which is a very common condition.  It involves dysfunctional male hormone production by the ovaries.  All females have male hormones to some extent, but a patient with PCOS usually has a much higher level and it affects her ovulation and ability to conceive.  It occurs in anywhere from five to fifteen percent of women, and is probably the most common single diagnosis seen in our office.

 

How does one diagnose PCOS in a patient?

Common symptoms of PCOS can include irregular or absent menstrual cycles, acne,   and excessive hair growth on chin, sideburns, lower abdomen and around nipples.  These are symptoms that are easy to see.  Once we look a bit deeper, we’ll see multiple small follicles in the ovary (referred to as antral count). An antral count of 12 or greater in one ovary is consistent with PCOS.  We’ll also run androgen blood levels which are often elevated with PCOS.  If a woman has two out of those three criteria – multiple follicles on the ultrasound, elevated male hormone levels, or irregular cycles – it’s likely we’re dealing with PCOS. 

 

What causes PCOS in women?

We really don’t know the cause.  There is some family history component, but there isn’t any genetic test to determine how likely a woman is to develop PCOS.  Women with a family history do have a higher chance of developing PCOS, but we have patients with no such history.  There are probably some environmental effects as well.  Some of our patients had no symptoms and conceived their first child without any treatment, then gained a significant amount of weight with their first child and started showing symptoms of PCOS.  Most cases we see are weight-related, and often a weight gain can push women over the edge of that hormonal balance and cause PCOS to show itself. 

 

What is the next step for a patient after PCOS has been diagnosed?

If it is PCOS, the basic decision is if this patient is trying to achieve pregnancy.  If she is, we help her ovulate and release eggs more effectively than her body has been previously.  If the woman isn’t trying to conceive, we focus on balancing out the hormone levels to help reduce her symptoms.

 

What treatment options are available for women with PCOS?

We spend time talking about what lifestyle management can do to help with symptoms, especially weight management.  Women with PCOS have a two to five time greater risk for developing diabetes.  Weight gain exacerbates PCOS symptoms.  Even a five to ten percent weight loss can improve PCOS symptoms and improve her response to fertility treatments.  We also encourage exercise, avoidance of excessive alcohol and no tobacco use. 

 

If the patient has never tried any fertility treatments, we will try fertility pills such as Clomid or Letrazole.  Clomid is the only FDA approved fertility pill for treatment of ovulatory dysfunction.   However, it has many side effects including irritability, formation of ovarian cysts, blurred vision, and adverse effect on cervical mucus and uterine lining.  For this reason we often use Letrazole as our first line fertility pill because it has less side effects and similar, if not better, pregnancy rates.  There is much acceptance of Letrazole use in the infertility literature.  We often combine ovulation enhancing drugs with Glucophage to lower insulin resistance.

 

If fertility pills are not successful, we usually move to gonadotropin therapy referred to as ovulation induction or super ovulation.   Success rates are as high as 20-25% per cycle, but multiple birth rate results are 20-25% twins, 5% triplets and a 2% chance of quadruplets or greater.  One way to avoid triplets or greater is to move to in-vitro fertilization where we can control how many embryos are transferred into the woman’s uterus.  With in-vitro fertilization, there are now ways to avoid ovarian hyperstimulation where ovaries swell to as much as 10 to 15 centimeters in size, much fluid weight is gained and often there are problems with keeping liquids digested.  Hospitalization is then sometimes needed.  The current thinking is for patients who have severe PCOS to use IVF, trigger ovulation with Lupron, a GnRH agonist, retrieve eggs and then freeze the embryos five days later at the blastocyst stage.  So far no severe hyperstimulation has been reported using this strategy.  Thawing of embryos at the blastocyst stage is now 90% successful and resulting pregnancy rates in frozen embryo cycles are excellent. 

 

What should women with PCOS remember?

We really want to encourage women with PCOS.  This is a very common diagnosis and it can be frustrating to women because there is considerable misinformation in the public domain about what PCOS is and what it is not.  Women with PCOS should be very encouraged about a future pregnancy.  This is something we see every day in our program and we have had great success in helping women conceive after a PCOS diagnosis.  There are many reasons to be hopeful about pregnancy success after a PCOS diagnosis.