2018 ASSEMBLY...Gina R. Vess, MACCC-SLP DukeUniversity Julie Blair, MA BCSCCC-SLP Medical University of SouthCarolina 1 What is your current managementfor: • Globus • Foreign bodysensation

This continuing medical education activity is jointly provided by the North Carolina Society of Otolaryngology and Head & Neck Surgery and

Southern Regional Area Health Education Center.

July 20-22, 2018 | Omni Grove Park Inn Resort | Asheville, NC

2018 ASSEMBLY

SUNDAY HANDOUTS

North Carolina/South CarolinaOtolaryngology and Head & Neck Surgery

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Samip N. Patel, MD, FACSTuesday, January 11, 2011

Defining Quality and Reducing Morbidity in Head & Neck Microvascular Surgery

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Oncologic Therapy

• Advanced Stage

• Large Tumors

• Aggressive Surgery

• Young vs Elderly

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Oncologic Therapy

• Data ‐ aggressive surgery, better oncologic outcomes?

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2

Role of FTT

• Restore Function and Cosmesis

• Standard of Care for Certain Defects

• Allows wider margin for resecting surgeon

• Specific sites

• Skull base

• Scalp

• Special circumstances

• Nose

• Partial Larynx

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Perception

• Unnecessary

• Morbid

• Mutilating/Deforming

• Prolonged Anesthesia Time

• Intensive Postop Course

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Reality

• Unnecessary

• Morbid

• Mutilating/Deforming

• Prolonged Anesthesia Time

• Intensive Postop Course

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3

Defining Quality

• No Consensus

• Flap Failure Rates?

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Quality Measures

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Quality Measures

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Reducing Morbidity

• Operative Time

• Anesthesia Time

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Reducing Morbidity

• De‐escalating Postoperative Care

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Reducing Morbidity

• Minimizing Hospital LOS

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Reducing Morbidity

• Incision Planning

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Reducing Morbidity

• Flap Selection

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Reducing Morbidity

• ERAS:

• Nutrition, Thromboembolism Prophylaxis, Postoperative Pain

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1

Globus and Muscle Tension Dysphagia:

Options for Management

Gina R. Vess, MA CCC-SLP Duke UniversityJulie Blair, MA BCS CCC-SLPMedical University of South Carolina

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What is your current management for:

• Globus

• Foreign body sensation

• Difficulty/effortful swallowing

• Pain in throat

Do you manage differently if they have truesigns of dysphagia and/or hoarseness?

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Incidence of Globus

• Prospective cohort study of 122 patients in small ENT practice (3 MDs)– Incidence was 3.8%

– 84% had anxiety

– 15.6% had GERD (what testing)

– “Reassurance” was primary recommendation

Rasmussen et al (2018)

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2

Globus pharyngeus: a review of etiology, diagnostics, and treatment

(Järvenpää, P., et al 2018) 4

Globus pharyngeus:A review of its etiology, diagnosis and treatment

Bong Eun Lee, Gwang Ha Kim (2012) 5

Muscle Tension Dysphagia (MTDg)

Kang etal

Table 1. Prevalence of Dysphagia Symptoms among Patients (N = 67).

Symptom n (%)

Difficulty swallowingsolids 25(37)Throat discomfort whenswallowing 22(33)Food sticking in the throat 20(30)Difficulty swallowingpills 10(15)Hard to swallow 9 (13)Coughing when eating or drinking 8 (12)Choking when eating or drinking 8 (12)Difficulty swallowingliquids 8 (12)Difficulty swallowing saliva 3 (4)Aberrant sound when swallowing 3 (4)Fatigue from swallowing 2 (3)

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3

MTDg Results

• 67 patients met inclusion criteria• 27 patients referred for SLP evaluation• 13 patients received therapy for MTDg• All 13 patients had resolution of dysphagia

symptoms

Limitations: Retrospective design

GERD/LPR not consistently evaluated(all normal videofluoroscopy does not = MTDg)

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Problem:When symptoms do not match examfindings

• Normal instrumental swallow evaluation(barium swallow or videofluoroscopy).

• Normal laryngoscopy

Explore possibilities the symptoms arerelated to muscle tension

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What can be done for “Muscle Tension”Dysphagia & Globus

Manual therapy techniques are:-skilled hand movements & skilled passive movements of joints and soft tissue-intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation, or restriction.

Guide to Physical Therapy Practicehttp://guidetoptpractice.apta.org/content/1/SEC38.extract

Jean Catuffe/Getty Imageswww.vox.com/science‐and‐health/2018

Fascial “deformation”

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4

Evidence – Systematic Review

• 133 articles (MFR)• 19 met inclusion criteria

– Peer reviewed RCTs– Articles in English

• 9 studies: MFR no better than sham• 7 studies: Better than control, sham, & control with

sham• 2 studies: Equally effective as other txs• MFR emerging as strategy w/solid evidence base &

tremendous potential

Ajimsha et. Al (2015)

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Principles of Treatment

• Gentle, sustained pressure over an area which is relevant– Pressure/pain?– Validation of symptoms

• Technique– Light pressure– Static hold– Bunching/gathering– Traction or pulling– Shearing/shifting/twisting

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Patient testimonials

• It’s easier to swallow.• It feels like there’s more space (in throat)• It feels less tight (in throat).• The lump (in throat) is less noticeable.• It feels less scratchy (in throat).• It feels less restricted (in jaw).• I don’t notice my throat anymore.• I haven’t had any more pain (in the throat).

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5

Are there signs of muscle tension?

– By history• Globus• Pain in throat• Difficulty swallowing (even just saliva)• Symptoms worsen with increased talking or as day

progresses

– By palpation• Tenderness or tightness anywhere around the larynx,

thyrohyoid space, BOT, and/or jaw.

– If so, consider speech pathology evaluation for voice or swallowing with therapy focusing on manual release of tension

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Case study 1: “Voice & MTDg”

• 44 y/o female

• Symptoms (onset 2 years prior):– Fullness in left neck

– Left ear feels plugged

– Difficulty swallowing:, Hard to swallow her saliva, feels meats and pizza "sticks," Trouble with pills sticking

– Trouble breathing

– Hoarseness, vocal fatigue

• Med Hx: Thyroid goiter – scheduled for thyroidectomy 1 week after our initial evaluation

• Strobe findings: mild bilateral midfold edema (pre-nodular),supraglottic hyperfunction

• Assessment: “Mild” (symptoms appeared related to strain)

• Treated as “voice therapy” – swallowing appeared to be MTDg

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Therapy strategies

• MFR techniques– Traction of larynx to each side

– Focal pull down of larynx

– BOT massage

• Traditional voice exercises– Semi occluded exercises

– Forward resonance practice

• Voice & swallowing resolved

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6

Pre-treatment• VHI = 26• RSI = 18

• Her assumption was that her symptoms were related to her thyroid

Treatment• Only 3 sessions of tx• Focus on releasing tension

w/MFR & semi-occluded vocal tract exercises

Post- treatment

• VHI = 7

• RSI = 5

• Complete resolution, did not go for unnecessary surgery (monitoring enlarged thyroid & small cysts with ultrasound)

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CASE STUDY 2: GLOBUS

– Asthma

– GERD

– Megacolon

– Prior H.Pylori Gastritis

• PSHx:

– Multiple endoscopies

– Oral surgery

– EGD with biopsies

– Lives with mother and step-dad

– Athlete - Long distance runner

– Graduating early

• 16 y/o female

• Symptoms: 1‐2 year history of feeling food, liquids, and pillsstick in throat

• PMHx: • Social History

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Instrumental Assessments

• MBS– Reduced PES release with obstruction of flow

– Residue in the pharynx

– Esophageal retention

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Instrumental Assessments

• High Resolution Manometry– Normal esophageal study

– Poor pharyngeal contractility in the inferior pharyngealconstrictor region

– Increased UES pressures

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Intervention

• Swallow Therapy– HRM Biofeedback

– Initial imaging revealed elevated UES pressures with inability to alter HRM readings

– Myofacial Release performed duringtreatment

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Myofacial Release

Suprahyoid Tension Anterior Cervical Spine

Images used with permission:Walt Fritz, PT (2016) “Foundations in Myofascial release Seminar for Neck,Voice, and Swallowing Disorders” www.FoundationsinMFR.com

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HRM Biofeedback During MFR

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Outcomes

• MFR performed to release UES tension with opening visible on HRM

• Carryover with visual feedback improved

• Positive and negative practice to improvemuscle control

• PO trials during HRM

• Resolution of globus complaints

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References

• Ajimsha, M.S, Al-Mudahka, N.R., Al-Madzhar, J.A. “Effectiveness of myofascial release: Systematic review of randomized controlled trials.” Journal of Bodywork & Movement Therapies. 2015; 19: 102-112.

• Fritz, Walt (Feb 2016) Foundations in Myofascial Release Seminars (2 dayworkshop, Charlotte, NC)

• Järvenpää, P., Arkkila, P. & Aaltonen, LM. Eur Arch Otorhinolaryngol (2018). https://doi.org/10.1007/s00405-018-5041-1 Epub ahead of print

• Kang, C.H., Hentz, J.G., Lott, D.G., “Muscle Tension Dysphagia: Symptomology and Theoretical Framework.” Otolaryngology-Head and Neck Surgery. 2016; 155(5): 837-842.

• Karkos PD1, Wilson JA. “The diagnosis and management of globus pharyngeus: our perspective from the United Kingdom.” Curr Opin Otolaryngol Head Neck Surg. 2008 Dec;16(6):521-4.

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• Krisciunas, G.P., Golan, H., Marinko, L.N., Pearson, W, Jalisis, S., Langmore, S.E. “A Novel Manual Therapy programme during radiation therapy for head and neck cancer – our clinical experience with five patients.” Clinical Otolaryngology 2015; 41: 402-431.

• McKenney, K, Elder, A.S., Elder, C. Hutchins,A. “Myofascial Release as a Treatment for Orthopedic Conditions: A Systematic Review.” Journal of Athletic Training. 2013; 48(4): 522-527.

• Roy, N. Bless, D., Heisey, D., Ford, C.N. (1997). “Manual circumlaryngeal therapy for functional dysphonia: an evaluation of short and long term treatment outcomes.” Journal of Voice (11): 321-331.

• Guide to Physical Therapy Practice

http://guidetoptpractice.apta.org/content/1/SEC38.extract

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1

Strategic Planning Principles

Tools to Solve the Challenges we face in Medicine

Will Harrill, MD FACSDavid Melon, MD FACS

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Healthcare 2018

• "Many of those who seek to disrupt healthcare are driven by financial motivations and are more concerned with satisfying their boards of directors and shareholders. It is our challenge, our obligation, and our responsibility as otolaryngologists to reshape the narrative in healthcare and to redefine how healthcare is delivered.”

Gavin Setzen, MD FACS AAOAPresident AAO‐HNS

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Strategic Planning: Market Disruption Forces

Market DisruptionMarket

Disruption

BIG BANGBetter and cheaper than

mainstream

Penicillin

Google maps

BIG BANGBetter and cheaper than

mainstream

Penicillin

Google maps

From ABOVE

Initially Superior but more expensive

becomes even better and less expensive

Cochlear implants

Smart phones

From ABOVE

Initially Superior but more expensive

becomes even better and less expensive

Cochlear implants

Smart phones

From BELOW

Initially inferior and more expensive

becomes superior and inexpensive

Ambulatory Surgery

Personal Computers

From BELOW

Initially inferior and more expensive

becomes superior and inexpensive

Ambulatory Surgery

Personal Computers

ARCHITECTURAL

New product radically changes how products or services are produced, managed, delivered and

sold

Managed Care

Amazon,

ARCHITECTURAL

New product radically changes how products or services are produced, managed, delivered and

sold

Managed Care

Amazon,

“in the” BEHIND

GOVERNMENT

Subsidized

Mandatory

Immune to market forces

EMRChange creates maximum opportunity! 3

2

Effects of Government DrivenMarket Disruption

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41

5

24

5

1

13

1 2 1 2

8

1 1 1 10

5

10

15

20

25

30

2011 – 2016: $36 Billion EHR subsidy paid out

2016 NC/SC Survey4

Market DisruptionGovernment Driven

EMR

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Market DisruptionPrivate Market Driven

Allergy EMR

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3

Key Components of Strategy

• Strategic Thinking– Dynamic Data Processing

• Factual Data

• Structural/Environmental Data

• Emotional Data

• Political Data

• Strategic Analysis (SWOT)– External and Internal Data

• Strategic Planning– 6 to 10 year vision

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Dynamic Data ProcessingOrganize and Analyze

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9

4

Strategic Analysis: SWOT

Internal

External

Strengths Weaknesses

Opportunities Threats

Traits within that can be leveragedin the future or mitigated thru strategic actions

Elements outsidewhich you have no control over, but that could (and should) affect your strategy

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Strategic Thinking: The Cognitive Trap

• The riddle of Experience vs Innovation

A True Paradigm Shift favors Innovation

$134 Billion $945 Billion$778 Billion

Not Strategic discipline 11

Strategic Planning is NOT Personal

• Patent #174,465– Bell Telephone offered to sell full patent to Western Union for $100,000 to resolve contentious litigation

($2.3 million in 2018 dollars)

“Utterly unreasonable offer….”

“Device with inherently of no use to us”

William OrtonPresident Western Union

187812

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Strategic planning: OverheadExpense vs Investment

• An Expense

– Incompletely integrated

– Disrupts efficiency

– Distracts from Quality of Care

– Hurts Employee Moral

– Only adds to depreciation

• An Investment

– Fully integrated

– Enhances efficiency

– Enhances Quality of Care

– Boosts Employee Moral

– Adds value and base for growth

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1

The American Board of Otolaryngology Update on Continuing Certification (MOC)

Mark C. Weissler, MD, FACS

Member, Board of Directors

American Board of Otolaryngology

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The American Board of Otolaryngology(ABOto) serves the public by assuringthat, at the time of initial certificationand during maintenance of certification,diplomates certified by the ABOto havemet the ABOto’s professional standardsof training and knowledge inotolaryngology‐head and neck surgery.

Mission:

AMERICAN BOARD OF OTOLARYNGOLOGY (ABOto)

PHYSICIAN ASSESSMENT

Med School ResidencyPractice

Applicationprocess

PD Eval‐uations

Certification exams

Credentialing

5 years

Residency applicationprocess

Tests &evaluations

USMLE &licensure

Continuing Certification

Continuing Credentialing (ongoing and focused professional practice evaluation)

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4 Parts:1. Professionalism and Professional Standing 2. Lifelong Learning and Self‐Assessment 3. Assessment of Knowledge, Judgment, and Skills4. Improvement in Medical Practice

A program in evolution

ABMS STANDARDS FOR CONTINUING CERTIFICATION

ABOto CONTINUING CERTIFICATION PHILOSOPHY

•Meet ABMS standards

•Be relevant to practice‐focus•Activities that are meaningful and add value

•Minimally time‐intrusive

•Continuous review and improvement of program

• Board certificate

• Unrestricted medical license

• Privileges at hospital/ASC

PART I – PROFESSIONALISM & PROFESSIONAL STANDING (DONE YEARLY)

3

• 25 AMA CME units/ year

• Online self‐assessment module (SAM)

PART II – LIFELONG LEARNING & SELF‐ASSESSMENT (DONE YEARLY)

SAM HOME PAGE

HEAD & NECK SAMs

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PANEL DISCUSSIONCONTROVERSIAL ISSUES

1(Low)

2 3 45

(High)4+5

The content of the module was accurate and up to date

3% 3% 10% 33% 51% 84%

The format of the questions was appropriate to the content presented

4% 6% 12% 33% 45% 78%

The diagnostic and management methods presented were free of author bias

4% 4% 11% 30% 51% 82%

The panel discussion was informative 3% 4% 18% 35% 39% 75%

This module helped me identify the strengths and the areas that need improvement in my practice

6% 6% 16% 33% 39% 72%

SAM EVALUATIONS

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• Secure closed book exam• Administered at testing centers• Practice‐focus specific; Practice‐oriented questions

• 80 questions

• Pass rate very high

PART III – ASSESSMENT OF KNOWLEDGE, JUDGMENT, AND SKILLS (ONCE PER 10‐YEAR CYCLE)

Allergy/Rhinology NeurotologyFacial Plastic & Reconstructive OtologyGeneral Otolaryngology Pediatric OtolaryngologyHead and Neck Surgery Sleep MedicineLaryngology

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PART IV – IMPROVEMENT IN MEDICAL PRACTICE (NOT CURRENTLY ACTIVE FOR ABOto)

• Currently under development• Reg‐ent• ACCME (Accreditation Council for CME)

• Portfolio Program (ABMS)• Participating institutions• Multidisciplinary quality improvement projects

ABOto TEN YEAR CYCLE

1 2 3 4 5 6 7 8 9 10

Questionnaire

SAM/CME

CBT Exam

Part IV

YEARLY SURVEY

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6

CertLinkTM

is Coming

ABOto CONTINUING CERTIFICATION PROGRAM

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CertLinkTM

is ComingAlternative to the “high stakes” exam• Fulfills Part III• Also get Part II credit


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CertLinkTM


No extra cost• Annual fee unchanged


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7

CertLinkTM



Quick and convenient• 10‐15 MCQs per quarter• Do at own convenience• No studying


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CertLinkTM



Quick and convenient• 15‐20 MCQs per quarter• Do at own convenience• No studying

Practice‐relevant questions• Tests “walking‐around” knowledge in your practice‐focus area

• Get immediate descriptivefeedback

• Identify knowledge gaps for pursuing focused learning activities


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•Collaborative initiative with ABMS

•Pilot project:•Will begin in Summer, 2018•Available for diplomates with 10‐year certificates that expire in 2019, and after

• Looking for volunteers for soft launch• Initial areas: Head and Neck, Facial Plastics, General

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Remaining questions for

this time segment

Clicking this button will resume an

assessment

Detail breakdown of performance and progress

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EHR Patient DataMastery of Breast Surgery Registry

Data InputRun Reports

MIPS ReportingMerit‐based Incentive

Payment System

Identify Areas for QI in Your Practice(MOC Part IV)

PART IV OPTION IN DEVELOPMENT

Accreditation Council for CME.

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THANK YOU

QUESTIONS?

Mark C. Weissler, MD, FACS Brian Nussenbaum, [email protected] [email protected]‐966‐8927 713‐850‐0399

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1

• Using Data Visualization Techniques to Accelerate and Improve Resident Recruiting

and Selection Processes• Sunday, July 22| 9:15 am

What if your data could tell you which questions to ask?

1

Overview“By 2020, 4x more digital data than sand

grains on Earth.”“By 2020, 4x more digital data than sand

grains on Earth.”

“Data are widely available; what is scarce is the ability to extract wisdom

from them.”

“Data are widely available; what is scarce is the ability to extract wisdom

from them.”

“By 2015, big data demand will reach 4.4 million jobs globally, but only one-third of

those jobs will be filled.”

“By 2015, big data demand will reach 4.4 million jobs globally, but only one-third of

those jobs will be filled.”

We have more data available to us today than in any time in history

(and we’ll have more tomorrow)

The Big Data Paradox: The proliferation of data can actually inhibit our ability to find insights

This discussion will highlight how data visualization can aid in both:

1)Insight Discovery; and 2)Communication of Findings

2

Introductions

Adjunct Associate Professor, Head & Neck Surgery & Communication Sciences at Duke University Health System

Associate Professor, Physical Medicine & Rehabilitation, Virginia Commonwealth University

Co‐investigator on several NIH and foundation‐funded initiatives with large and/or complex data sets

Interested in exploring approaches to aggregate and display data in compelling ways!

Nothing to disclose (no formal relationship with SynGlyphX)

Kristine Schulz, DrPH, MPH

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Why Visualize?• Needed a way to help us to make sense of these various datasets and their individual complexities

• Learned the ropes with visualizing via case study on tonsillectomy bleed rates; and allergy care patterns in NC• Lee, W. T., Witsell, D. L., Parham, K., Shin, J. J., Chapurin, N., Pynnonen, M. A., ... & Roberts, R. S. (2016). Tonsillectomy bleed rates across the CHEER practice research network: Pursuing guideline adherence and quality improvement. Otolaryngology‐‐Head and Neck Surgery, 155(1), 28‐32.

• Crowson, M. G., Schulz, K., Ulvila, A., & Witsell, D. L. (2018). Payer database and geospatial analysis to evaluate practice patterns in treating allergy in North Carolina. American journal of otolaryngology, 39(1), 20‐24. 4

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Why Visualize Resident Data?

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Why Visualize Resident Data?

• Data visualization techniques have been pioneered by the University of Notre Dame and are being deployed in other university Enrollment Management offices to support undergraduate and graduate recruiting, selection, and student success initiatives.

• Similar efforts underway with multiple NFL teams to support player evaluation and selection, and injury prevention.

• Similar efforts underway with the US DOD to apply the visualization techniques to evaluate complex human performance data (e.g., demographics, deployment, time in service, criminal activity, etc.) to identify suicide risk factors of military personnel.

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The Case Study

3‐D Visualization of Resident Variables to predict success in program at Duke HNSCS (n=30). Variables included:

“Traditional” variables:• USMLE scores• Med school rotation ratings• # of publications• In‐service stanine ranks• Professional memberships and academic career pursuit“Holistic” variables:• Sex• Marital and family status• State• Med school 8

The Case Study

Breaking down the visualization – via Video:

[LINK REMOVED FOR SUBMISSION; FILE SIZE]

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4

The Case StudyPreliminary Results of Visualization:

1. AS WITH LITERATURE, TRADITIONAL VARIABLES DID NOT SHOW UP ON VISUALIZATION AS INDICATIVE OF SUCCESS

2. VISUALIZATION SUPPORTED INCLUSION AND EXPLORATION OF HOLISTIC VARIABLES INCLUDING THE STATE THE RESIDENT IS FROM; AND FOR MALES, WHETHER OR NOT THEY ARE MARRIED AND HAVE A FAMILY

3. OPENS CONVERSATION OF PROGRAM’S DEFINITION OF “SUCCESSFUL” RESIDENT (WHICH WILL HELP DRIVE THE APPROACH TO SELECTION).

4. LIMITATIONS: NEED BIGGER N TO CONTINUE LEARNING

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Conclusion

Visualization…

Engages creativity in our thinking ‐‐ opening the doors to finding something we didn’t know we were looking for

Is our crystal ball allowing for the data to guide us versus us guiding the data

Is an excellent way to complement traditional statistical approaches

Is a way to bring different disciplines together “seeing” each other’s perspectives on what data is telling us

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Q&AThank you for your time!

Questions??

[email protected] 12

1

Should we work up small incidental thyroid nodules?

Dan Rocke, MD JD FACS

Matthew Crowson, MD

Jenny Hoang, MBBS MHS

1

Disclosures

• None

2

Outline

• What to do about incidentally discovered thyroid nodules?

• Different workup recommendations

• Cost‐effectiveness primer

• Our study

3

2

What to do about incidental thyroid nodules?

• Seen in 16% of CT/MRI, 5% of PET/CT

• Workup is costly• Imaging alone is ~$1500

• Some patients will need FNA, repeat imaging, surgery, molecular testing, etc.’

• Malignancy rate varies based on imaging modality• Ultrasound – 12%

• CT/MRI – 0‐11%

• PET with focal uptake – 33‐35%

Bahl M, Sosa JA, Eastwood JD, Hobbs HA, Nelson RC, Hoang JK. Using the 3‐tiered system for categorizing workup of incidental thyroid nodules detected on CT, MRI, or PET/CT: how many cancers would be missed?. Thyroid. 2014 Dec 1;24(12):1772‐8.Hoang JK, Raduazo P, Yousem DM, Eastwood JD. What to do with incidental thyroid nodules on imaging? An approach for the radiologist. InSeminars in Ultrasound, CT and MRI 2012 Apr 30 (Vol. 33, No. 2, pp. 150‐157). WB Saunders.Hoang JK, Langer JE, Middleton WD, Wu CC, Hammers LW, Cronan JJ, Tessler FN, Grant EG, Berland LL. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. Journal of the American College of Radiology. 2015 Feb 1;12(2):143‐50.

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Different recommendations

• American Thyroid Association• Recommends further workup for all incidentally discovered thyroid nodules

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Different recommendations

• American College of Radiology• If over 35 years old, and no other concerning findings (PET‐avidity, lymphadenopathy, local invasion) only work up nodules 1.5 cm or greater

• <35 years old, and no other concerning findings, only those >1 cm.

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3

Cost‐Effectiveness Analysis (CEA)

• What is it???• Cost

• Pretty obvious

• Depends on the perspective of your study, but includes things like lost wages, lost productivity, cost of treatments, transportation costs

• Effectiveness• Different ways to measure this

• Typically quality adjusted life years, or QALYs

• 1 year of life in perfect health counts more than 1 year of life disabled

• Utility score of 1 corresponds to perfect health

• Utility score of 0 corresponds to dead

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• If something is more expensive and less effective, it is “dominated” by something that is less expensive and more effective…an easy decision

• If something is more costly and more effective…not so easy

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• Incremental cost‐effectiveness ratio (ICER)• Difference in cost of two interventions divided by the difference in effectiveness

• The cost per one unit of effectiveness

• In health care CEA, typically the cost per QALY gained

• How do you use this?• Willingness to pay threshold (WTP) – an assumption of what society is willing to pay for a gain in QALY

• Usually assumed to be $50,000 to $100,000

• Net monetary benefit (NMB)• (Effectiveness x WTP) – cost

• A way to compare interventions head‐to‐head

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4


• Perspective• The point of view of a CEA study

• Patient perspective• Takes into account costs to and utilities for the patient only

• Hospital perspective• Would ignore effects on patient and society

• Societal perspective• Takes into account all costs and utilities

• The recommended perspective for CEA

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• How do you do this analysis?

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CEA of incidentally discovered 1.4 cm thyroid nodule• Base case 45 year old female with incidentally discovered 1.4 cm thyroid nodule on CT

• A Markov model was developed for two strategies• Workup

• ATA guidelines

• Ultrasound and FNA when appropriate

• No workup• ACR guidelines

• No follow‐up

• A societal perspective was assumed with a 20‐year time horizon

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https://radiopaedia.org/blog/reporting‐of‐incidental‐thyroid‐nodules‐on‐ct‐and‐mri‐1

10‐14 mm incidentalthyroid nodule

No Work‐Up

FNA

M

NED After Recurrence

Initial Work‐Up

NED

Undetected Cancer

Thyroid Cancer Survivor

Dead Thyroid Cancer, Other Cause

No Thyroid Cancer

Alive(or die from thyroid cancer, other cause)

Stays NED, Local Dz, Regional Dz, Distant Dz

Markov

Model

Costs Accounted for:• Consultation, follow‐up• Surgery: lobectomy, total thyroidectomy• Labs: TSH, Thyroglobulin, Affirma, FNA, pathology• Imaging: ultrasound, CT neck & chest, whole‐body scan• Radioactive iodine (I‐131)

Alive(or die from thyroid

cancer, other)

Alive(or die from thyroid

cancer, other)Clinically Significant or

Insignificant

Alive(or die from thyroid cancer, other cause)

Stays NED, Local Dz, Regional Dz, Distant Dz

Benign

OtherFollicular

Suspicious/Malignant

Non‐Diagnostic/Unsatisfactory

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CEA of incidentally discovered 1.4 cm thyroid nodule• Assumptions

• Cancers will be discovered clinically after 5 years of growth and be 3‐4 cm

• Surgeries are done without complication

• Probabilities• Prevalence of malignancy – 4%

• Clinically significant cancer – 27%

• Progression of undetected cancer to higher stage – 10%

• Survival

• Based on size of either 1.4 cm or 3‐4 cm, from SEER database

• Adjusted for regional or distant disease

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6

CEA of incidentally discovered 1.4 cm thyroid nodule• Distributions were created for costs, utilities, and state transition probabilities

• A two‐way Monte Carlo (sampling & trials) analysis was run with 10,000 samples and 10,000 trials

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CEA of incidentally discovered 1.4 cm thyroid nodule• Results

• Mean Cost• No workup ‐ $248.56 (CI 97.5%: 301.07‐198.95)• Workup ‐ $2,456.67 (CI 97.5%: 2560.03‐2353.15)

• Mean Effectiveness• No workup – 13.75 QALY (CI 97.5%: 13.79‐13.68)• Workup – 13.75 QALY (CI 97.5%: 13.79‐13.71)

• ICER – FNA vs no workup• $822,871.52

• NMB• No workup ‐ $687,336.79• Workup ‐ $685,262.85

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CEA of incidentally discovered 1.4 cm thyroid nodule

00.10.20.30.40.50.60.70.80.9

1

$-

$5

,00

0

$1

0,0

00

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cti

ve

Willingness to Pay (U.S. Dollars)

FNA 10-14 mm ITNNo work-up 10-14

18

7

CEA of incidentally discovered 1.4 cm thyroid nodule

19

Questions?

20

1

When should I send my patient for a cochlear implant?Ted McRackan MD, MSCR

2018 NC/SC Aseembly

7/22/18

Changing indications

Improved performance

2



+Rapidly improving technology

3

2



+Rapidly improving technology

Expanding indications

=

4

Expanding cochlear implant indications

• 1972 3M House Device


• 1984 single channel electrode in adults

• 1987 multichannel electrode in adults

• 1990 children >2 years old

• 1998 children >18 months

• 2000 children >12 months

3

Current adult CI indications

• Moderate to profound SNHL

• <50% open set speech recognition• <60% in best listening condition

• CMS: <40% speech recognition

• Type of speech testing very vague• Word recognition (CNC)

• Sentence recognition in quiet (AzBio)

• Sentence recognition in background noise (AzBio +5/+10)



4


• No speech recogntion60%*

• 6-10% of adults who are eligible receive cochlear implants

When should you refer patients for CI evaluations?• No established criteria on routine office-based audiometry for

when to refer for formal CI evaluation

Vs.

• 139 subjects evaluated• 50.4% female

• Average age: 63.1 years

• 102 qualified for implantation

5

• Results• Worse pure tone thresholds up to 6,000 Hz correlated with worse

speech recognition ability

• 83.3% of patients with pure tone thresholds >54.7 dB at 250 Hz were CI candidates*

• Speech recognition testing:

• WRS <30.2%: 87% were CI candidates based on HINT

• WRS <39.2%: 93.3% were CI candidates based on AzBIO +5

• Data are sensitive, but may lack specificity

• Provide good baseline for CI referral

• Are these values too restrictive?

6

Standard audiogram

• Pure tone audiometry

• Earphone speech recognition score

Standard audiogram

• Does earphone WRS predict aided word recognition ability?

NO

What about patients with worse word recognition?

• Retrospective review of data obtained during CIEs

• Inclusion criteria:

› ≥18 year old

› Underwent a CIE between 1/2012 and 12/2017

• Exclusion criteria:

› <10% earphone word recognition

• 208 ears met cirteria

7

• Mean difference between headphone and hearing aids: +14.3%

• 52 ears (25%) performed better with hearing aids

• 156 ears (75%) performed better with headphone

• No differences in demographic or hearing aid use between groups

Results

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

CN

C (

%)

Earphone CNC (%)

-EAD

+EAD

Earphone to Aided Difference

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

CN

C (

%)

Earphone CNC (%)

-EAD

+EAD


• 6.7% above 95% CI

8

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

CN

C (

%)

Earphone CNC (%)

-EAD

+EAD


• 6.7% above 95% CI

• 51.9% below 95% CI

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

CN

C (

%)

Earphone CNC (%)

-EAD

+EAD


• 6.7% above 95% CI

• 51.9% below 95% CI

• Earphone scores do not adequately represent patients’ aided communication ability

Patients with >50% earphone word recognition

9

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

CN

C (

%)

Earphone CNC (%)

-EAD

+EAD

0

20

40

60

80

100

0 20 40 60 80 100


0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

CN

C (

%)

-EAD

+EAD

0

20

40

60

80

100

0 20 40 60 80 100Earphone CNC (%)


• 34 out of 37 subjects (91.9%) in this group had aided word scores ≤ 50%

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

AzB

io (

%)

Earphone CNC (%)

-EAD

+EAD

Sentence Recognition

in Quiet

10

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

AzB

io (

%)

Earphone CNC (%)

-EAD

+EAD

0

20

40

60

80

100

0 20 40 60 80 100


• 17 out of 28 subjects (60.7%) had aided sentence scores ≤ 50%

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

AzB

io (

%)

Earphone CNC (%)

-EAD

+EAD

0

20

40

60

80

100

0 20 40 60 80 100


• 17 out of 28 subjects (60.7%) had aided sentence scores ≤ 50%

• 14 subjects (50%) scored less ≤ 40%

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

AzB

io +

10

(%

)

Earphone CNC (%)

-EAD

+EAD

Sentence Recognition

in Noise

11

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

AzB

io +

10

(%

)

Earphone CNC (%)

-EAD

+EADPatients with >50% earphone word recognition

• 19 out of 23 subjects (82.6%) had aided sentence recognition scores ≤ 50% when tested in noise

0

20

40

60

80

100

0 20 40 60 80 100

0

20

40

60

80

100

0 20 40 60 80 100

Aid

ed

AzB

io +

10

(%

)

Earphone CNC (%)

-EAD

+EAD


• 19 out of 23 subjects (82.6%) had aided sentence recognition scores ≤ 50% when tested in noise

• 18 subjects (78.3%) scored less ≤ 40%

0

20

40

60

80

100

0 20 40 60 80 100

The need to routinely test aided speech recognition ability

• 80% of patients with earphone CNC scores >50% were cochlear implant candidates

• Earphone scores poorly estimate aided communication ability

12

Conclusion

• Earphone scores poorly estimate aided communication ability

• Many patients with earphone scores >50% are cochlear implant candidates

• Highlights the importance of monitoring aided speech recognition in routine audiologic evaluations

• Valuable in deciding treatment options for hearing loss

Questions?

1

Lipoblastoma of the Thyroid

Edward J. Doyle III, MD

Wake Forest Baptist Health

1

Disclosures

• Nothing to Disclose

2

Plan

• Our case study

• Review of Literature

• Management

• Questions

3

2

Case RC

• RC 17 month old male

– presented to clinic for evaluation of a neck mass that had been present for the last 3‐4 months.

–Mass stable in size during this time

• No recent infections, sick contacts, pain, weight loss.

• Swallowing normally.

4

Case RC

• Birth History: Born at 32 week 6/7 days. NICU for fourth months. Complicated by necrotizing enterocolitis.

• Family History: healthy

• Surgical History: Ex lap, segmental small bowel resection x 3, abdominal washout, end jejunostomy (s/p reversal), appendectomy

5

Physical Exam

• ~5 cm firm mass in right neck

• Normal skin

• No pit seen

• Normal voice

• No stridor

6

3

CT Neck/Thryoid with IV contrast :

7

Management

• Taken to OR 7/3/2017:

– Excision right neck mass with thyroid lobectomy

– Excision of deep cervical lymph node, right

• Findings:

– Neck mass in right thyroid

– Recurrent laryngeal nerve identified

– Frozen consistent with myxoid pathology

– Large jugulodigastric lymph node

8

Follow Up

• 6 month:

–Well healing incision

– No evidence of neck mass

– No difficulty breathing

– Normal voice

9

4

Background

• Infancy

• Found on extremities most commonly.

• Reports of H&N lipoblastoma are few

– Shah A, Wei J, Maddalozzo J. Cervical Lipoblastoma: An uncommon diagnosis of neck mass. Otolaryngol Head Neck Surg 2004; 130:504‐7.

10

Background

• Pham N, Poirier B, Fuller S, et al. Pediatric lipoblastoma in the head and neck: A systematic review of 48 reported cases. Internat Journal of Pediatric Otorhinolaryngology 74 (2010) 723‐728.

–Male to female; 2:1

– >90% present in first three years of life

– Presenting symptom: painless enlarging neck mass (53% 17/32).

11

Background

• Recurrence rate 27%

– For those with follow up at a year (5/19 cases)

– Remainder no follow up was found

• No malignant transformation

• Differential diagnosis:

– Lymphangioma

– Teratoma

–Myxoid liposarcoma

12

5

Pathology

• Lipoblastoma vs Lipoblastomatosis

• Multilobular pattern grossly

• Prominent fibrous septae separating the liboblasts

13

Radiology

• MRI is the preferred imaging modality

– T1 weighted MRI image intensity.

– T2 hyperintense

14

Management

• Surgical excision

– Recommended, but with sparing of critical structures

• Spontaneous resolution

–Mognato G Cecchetto G. Is Surgical Treatment of Lipoblastoma Always Necessary? Journal of Pediatric Surgery. 2000: 1511‐1513.

• Serial MRI

15

6

Recap

• 18 mo old with a stable, firm neck mass emanating from the right thyroid gland.

• Something to add for differential diagnosis

• Surgical excision should not be extremely aggressive

16

Works Cited

• Kumar A, Brierley D, Hunter KD, Lee N. Rapidly growing buccal mass in a 6‐mont‐old infant. British Journal of Oral and Maxillofacial Surgery 53 (2015) 888‐890.

• Mognato G Cecchetto G. Is Surgical Treatment of Lipoblastoma Always Necessary? Journal of Pediatric Surgery. 2000: 1511‐1513.

• Pham N, Poirier B, Fuller S, et al. Pediatric lipoblastoma in the head and neck: A systematic review of 48 reported cases. Internat Journal of Pediatric

• Shah A, Wei J, Maddalozzo J. Cervical Lipoblastoma: An uncommon diagnosis of neck mass. Otolaryngol Head Neck Surg 2004; 130:504‐7.

17

7/6/2018

1

NO FINANCIAL DISCLOSURES

Christopher T. Grubb, M.D.

Anesthesiology and Pain Management

Greenville, North Carolina

East Carolina Anesthesia Associates

East Carolina Pain Consultants

1

Prescription Medication Abuse: An Epidemic with Many Potential Causes

o Prescribing controlled medications withoutadequate screening or monitoring

o Dramatically increased rates of prescribingopioid analgesics

o Expansion into chronic non‐malignant pain

o Past criticism of prescribers as “opioid‐phobic”

o Regulatory changes (e.g. pain as the “5th vital sign”)

2

Prescription Medication Abuse: An Epidemic with Many Potential Causes

o Public expectations regarding treatmento Preference for “pill to get rid of pain” vs pain

management

o Perception that pain treatment = opioid treatment

o Preference for quick fix rather than comprehensive and multidisciplinary care

o History of opioid effectiveness for acute painsyndromes

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Balance Risks Against Potential Benefits of Opioids

Conduct thorough H&Pand appropriate testing

Comprehensive benefit‐to‐harm evaluation

o Overdose

o Life‐threatening respiratory depression

o Abuse by patient, family, or others

o Misuse & addiction

o Physical dependence & tolerance

o Interactions with other medications & substances

o Risk of neonatal withdrawal syndrome with use during pregnancy

Benefits Include: Risks Include:

Chou R, et al. J Pain. 2009;10:113-30. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010. FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. Modified 08/2014.

o Analgesia (adequate pain control)

o Improved Function

o Cardiovascular safety

o No ceiling effect

o Multiple drug choices

7

Classification of Paino Acute Pain:

o Pain persisting up to 3 months, usually associated with recent tissue injury (such as after surgery)

o Chronic Pain:

o Pain persisting for longer than 3‐6 months; usually the result of a pathological neurologic cascade (likely during the acute pain phase)

o Appropriate treatment of acute pain can improve long‐term outcomes

8

Central SensitizationAlso known as CNS wind‐up

oC‐fibers stimulate release of inflammatory mediators in dorsal root ganglion (near spinal cord)

oInvolves prostanoids, cytokines, Ca2+‐channels, TNF‐α, NMDA, and others

oProlonged central sensitization is theorized to be the root cause of most chronic pain conditions

Goal: Prevent/Treat CNS sensitization

9

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Target: Dorsal Root Ganglia and Spinal Cord

COX-1/2cytokines

PGE2

Peripheral sensitization

COX-2, glutamate

+ NMDA Ca2+-channels

Central sensitization

Injury (release of mediators)

Peripheral sensitization

Central sensitization

Worsening Pain

Woolf CJ. Mechanism-based pain diagnosis: issues for analgesic drug development. Anesthesiology 2001; 95: 241-9

10

Alternatives for Acute Pain

o Acetaminophen – 1000mg q4‐6h

o Tramadol – 50‐100mg q4‐6h (max 400mg/d)

o Nonsteroidal Anti‐inflammatories (NSAIDs)o Selective COX‐2 inhibitor equally effective as

hydrocodone/APAP 7.5/750 after sinus surgery1

o NSAIDs and bone healing – recent systematic review reveals poor evidence, no consensus2

o Celecoxib has no affect on platelets at supra‐therapeutic doses3

1 Church CA, et al. Laryngoscope. 2006 Apr;116(4):602‐6.

2 Marquez‐Lara A, et al. JBJS Rev. 2016 Mar 15;4(3).

3 Leese PT, et al. J Clin Pharmacol. 2000. Feb;40(2):124‐132.

11

Classification of Chronic Pain

NociceptiveoConstant dull, aching, throbbing

o Examples: bone/joint/muscle pain, cancer pain

Neuropathic – Due to central/peripheral nervous system dysfunction (synaptic hyperactivity of nociceptors and interneurons)

oBurning, stinging/tingling/prickly, sharp, lancinating

o Examples: radiculopathies, neuralgias, RSD/CRPS

oRelatively resistant to opioids

12

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Neuropathic Pain Therapyo Antiepileptics – pregabalin (Lyrica) 150‐600mg,

gabapentin 1800‐3600mg (1800 mg/d minimum)

o Serotonin‐Norepinephrine Reuptake Inhibitors (SNRI) –amitriptyline, duloxetine (Cymbalta)

o NSAIDs, acetaminophen – scheduled dosing

o Transcutaneous electrical nerve stimulation (TENS) therapy

o Steroid‐based interventional procedures

o Neuromodulation/Spinal Cord Stimulation

o Topical preparations (such as lidocaine) 13

Clinical Interview: Pain Characteristics

Heapy A, Kerns RD. Psychological and Behavioral Assessment. In: Raj's Practical Management of Pain. 4th ed. 2008;279‐95. Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. 2nd ed. Newton, MA: Inflexion, Inc., 2010.

Location IntensityOnset/Duration

Variations / Patterns / Rhythms

What relieves the pain?

What causes or increases pain?

Effects of pain on physical, emotional, psychosocial function

Patient’s pain & functional goals

What relieves the pain?

Quality

Description of pain

14

Clinical Interview: Pain Treatment History

Past use

Current useo Query Controlled Substances Reporting System (CSRS)

o Contact past providers & obtain prior medical records

o Conduct Urine Drug Testing (UDT)

Dosageo For opioids currently prescribed: opioid, dose, regimen,

and duration

o Important to determine if patient is opioid tolerant

General effectiveness

Pain Medications

Non‐pharmacologic therapy

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Clinical Interview: Patient Medical History

Illnesses relevant to the effects of opioids: oPulmonary disease, especially sleep apneaoCognitive impairment, dementia

Illnesses possibly linked to substance abuse:

Hepatitis HIV Tuberculosis Cellulitis

STIsTrauma, burns

Cardiac disease

Pulmonary disease

Chou R, et al. J Pain. 2009;10:113‐30. Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. 2nd ed. ewton, MA: Inflexion, Inc., 2010. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010. 16

Ensure Patients Understand Limitations of Opioid Therapy

Emphasize BEFORE beginning trial of opioid therapy:

o Pain treatment does not equal opioids.

o Opioids are not equally effective for all types of pain.

o Opioids are rarely sufficient as stand‐alone therapy.

o Primary goal is functional improvement (not eliminating pain)

o Opioids have significant associated risks: impairment, dependence, overdose.

Therefore... Continuing opioid treatment depends on:

o Demonstrated efficacy (improved function and pain)

o Demonstrated safety (no adverse effects or aberrant medication‐taking behaviors)

17

Primum Non Nocere “First, Do No Harm”

High risk of drug abuse

Concomitant CNS depressants (especially anxiolytics)

Obstructive Sleep Apnea or significant pulmonary disease

Long‐acting opioids for

acute or short‐term pain

Opioid dose based on severity or character of

pain

Opioid dosing without

consideration of opioid tolerance

18

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Consequence of Chronic Opioid Use

19

Opioid‐Induced Respiratory Depression

o In elderly, cachectic, or debilitated patients

o If given concomitantly with other CNS depressants

o During initiation of opioid therapy

o During periods of dose titration

o During transition to a new opioid

o *Contraindicated in patients with respiratory depression or conditions that increase risk

More likely to occur

o Proper dosing and titration are essential for opioid products

o Do not overestimate dose when converting from another opioid... Can result in fatal overdose withvery first dose

o For extended‐release opioids, instruct patients to swallow tablets/capsules whole... Dose from cut, crushed, dissolved, or chewed tablets/capsules may be fatal, particularly in opioid‐naïve patients

Reduce risk

FDA. Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 08/2014. www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf

20

Primary Goal of Opioid Therapy: Functional Improvement

o Returning to work

o Ability to perform routine activities

o Improved relationships, especially with family

o Participating in recreational activities

o Goal should NOT be to eliminate pain

o Alleviating pain is LESS important than increasing physical functioning!

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Standard of Care:Multimodal Approach to Chronic Pain

Therapyo Pharmacologic

o Non‐opioid (NSAIDs, Tylenol, antiepileptics, antidepressants, muscle relaxers)

o Opioids, long‐acting and/or short‐acting agents

o Topical agents

o Physical therapy, aquatic therapy, massage therapy, TENS

o Interventional/Injection therapies

o Steroid‐based (epidural, nerve blocks, intra‐articular, trigger‐points)

o Non‐steroid (spinal cord stimulation, nerve ablation)

o Surgical interventions

22

North Carolina Medical Board Position Statement (CDC Opioid Guidelines)

“NCMB’s primary goal relative to opioid prescribing is to prevent inappropriate prescribing, not to disrupt the treatment of patients with a legitimate need for pain management.”

Reassess

oPain, function

oRisk ‐ CSRS, UDT

oAvoid >90 MME

Optimize non‐opioid therapy

oMeds

oPhysical therapy

oInjectionsPrescribe short‐acting opioids first... low doses, small supply

Assess Risk factors23

CDC OpioidChecklist

←

CDC Opioid Guideline App:

24

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Assess Risk of AbuseSubstance Use and Psychiatric History

o Prescription drugs

o Illegal substances

o Alcohol & tobacco

o Substance abuse history does not prohibit treatment with opioids, but may require additional monitoring and expert consultation/referral

o Family history of substance abuse & psychiatric disorders

o History of sexual abuse

Social history is also relevant...

o Employmento Cultural backgroundo Social networko Marital historyo Legal history

25

Prescription Drug Monitoring Programs (PDMP's)

o North Carolina Controlled Substances Reporting System (CSRS) Database

o Available online 24/7

o Discuss with patients

o Prescribers can check their own prescribing history

Database of controlled substance prescriptions

o Existing prescriptions not reported by patient

o Multiple prescribers and/or pharmacies

o Drugs that increase overdose risk when taken together

o Patient pays for drugs of abuse with cash

Provide warnings of potential misuse or abuse

26

NC CSRS

27

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NC CSRS

28

Low Risk Medium Risk High Risk

Pain Etiology Clear/Identified Vague/Non‐specific

Substance Abuse Negative family or personal history

Past history butstable recovery

Active abuse oraddiction

Psychiatric History None Few/stable Multiple/unstable

Environment Stable/SupportiveResources

Unstable/Few resources

ActivityEngagement

Employed, active, engaged in other therapies

Unemployed,Inactive, takes only opioids for pain

CSRSOne prescriber/ Low opioid dose/No benzodiazepines

One prescriber/ Moderate opioid dose/ Benzos

Multiple prescribers/ High doses/ Benzos/Irregularities

29

Abuse and Dependence: “Addiction”

o Use of a medication outside the normally accepted standard for that drug.

o Recurrent problems in multiple life areas.

o Continued use in spite of negative consequences.

o Preoccupation with the drug, drug seeking behavior.

o Loss of control of use.

o Tolerance or physical dependence may or may not be present.

o Physical dependence and/or opioid tolerance is not the same as abuse or addiction!

Adapted from DSM IV, APA,1994.

30

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Aberrant Medication Taking Behaviors:

Differential Diagnosiso Misuse (confusion, poor understanding of drug regimen or rules)

o Pseudoaddiction1 (seeking ongoing or better pain relief from a particular drug or class of drugs)

o Opioid‐resistant pain (or pseudo‐resistance)2

o Opioid‐induced hyperalgesia3 (unrelieved or worsening pain with escalating opioid doses)

o Abuse/Addiction

o Chemical coping (self‐medication of psychological stress)

o Diversion1Weissman DE, Haddox JD. 1989; 2 Evers GC. 1997; 3 Chang C et al 2007 31

o Recognize & document aberrant drug‐related behavior

o Query CSRS database

o Perform urine drug testing (UDT)

o Positive for non‐prescribed controlled substances

o Positive for illicit substance

o Negative for prescribed opioid

o Family member or caregiver interviews

o Opioid monitoring questionnaires

o Medication reconciliation (e.g., pill counts)

Monitor Adherence & Aberrant Behavior

32

Reasons for Discontinuing Opioids

No progress toward therapeutic goals

Intolerable & Unmanageable Side

Effects

o 1 or 2 episodes of increasing dose without prescriber knowledge

o Sharing medications

o Unapproved opioid use to treat another symptom (e.g., insomnia)

o Use of illicit drugs or unprescribed opioids

o Repeatedly obtaining opioids from multiple outside sources

o Prescription forgery

o Multiple episodes of prescription loss

Nonadherence or unsafe behavior

Aberrant behaviors suggestive of addiction and/or diversion

Pain level decreases in stable patients

33

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Challenge: The Broken Stereotype

ACTION:

Require all patients receiving opioids to followa treatment plan and adhere to defined expectations. Evaluate risk in all patients. Usepatient‐provider agreements, contracts, or other tools.

Making assumptions

about a patient’s risk

without objective evidence

Ms. Yeun seems like a “good” patient. She has never abused opioids previously. She has been in the practice a long time, has never been a problem, and in fact, is rather enjoyable. She always brings Christmas cookies for the staff around the holidays.

Red Flag

34

Challenge: The Friday Afternoon Patient

ACTION:

•Check CSRS database.

•Employ opioid‐risk screening tools

•Utilize urine drug testing

•Be willing to say no

Patient requests new opioid or a

dosage increase at an

inopportune moment for the

provider

It's 4 pm on Friday and you are four patients behind schedule. Mr. Kingston arrives without an appointment and asks you to increase his current dosage of hydrocodone because it's not relieving his pain. It would take you two minutes to say yes.

Red Flag

35

STOP Act signed into law on June 30, 2017

Strengthen Opioid Misuse Prevention (STOP) Act of 2017 Sponsored by Dr. Gregory Murphy, Rep. NC House

Exceptions:

o Inpatient settings

o Treatment of cancer pain or palliative care

Definitions:

o Applies only to “targeted controlled substances” defined as Schedule II and III opioids.

o “Acute pain” – pain resulting from disease or trauma which is expected to last <3 months

o “Chronic pain” – pain lasting >3 months or beyond the time of normal tissue healing

36

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13

STOP Act (continued)o Mandatory electronic prescribing (effective 2020)

o Physician Assistants, Nurse Practitioners “shall personally consult” with supervising physician:

o When patient is treated in a pain clinic setting

o If opioid therapy is expected to exceed 30 days

o Acute pain – 5‐day limit on opioid Rx supply; 7‐day limit for surgical pain; no restriction on refills

o Controlled Substances Reporting System (CSRS)

o Mandatory query (preceding 12 months) prior to new prescription

o At least every 90 days during chronic opioid therapy

37

STOP Act Timeline

Additional supervision requirement for PAs and NPsJULY 1, 2017

New requirement that pharmacies report Rx within 24h (instead of 72h)

SEPT. 1, 2017

Opioid prescription limit (5 days for acute pain; 7 days for post‐surgical acute pain)

JAN. 1, 2018

Electronic prescribingJAN. 1, 2020

CSRS mandates – DHHS working on CSRS upgrades (more user‐friendly, improved analytics, inter‐state connectivity, and integration into EMR and the NC health information exchange)

TBD

38

Summary

Prescription opioid abuse & overdose is an epidemic in NC... Clinicians must play a role in prevention

Know how to manage ongoing therapy with opioids

Know how to counsel patients & caregivers about the safe use of opioids, including proper storage & disposal

Be familiar with general and product-specific drug information concerningopioids

Be familiar with how to initiate therapy, modify dose, &discontinue use of opioids

Understand how to assess patients for treatment with opioids

39

13

Documents

2018 ASSEMBLY...Gina R. Vess, MACCC-SLP DukeUniversity Julie Blair, MA BCSCCC-SLP Medical University of SouthCarolina 1 What is your current managementfor: • Globus • Foreign bodysensation