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Gov. Ivey Proclaims September Rheumatic Disease Awareness Month

Gov. Ivey Proclaims September Rheumatic Disease Awareness Month

If you suffer from the pain of arthritis, lupus or fibromyalgia, then you understand the scope of a rheumatic disease. Rheumatic diseases are the leading cause of disability in the United States and affect one-in-four Americans. By the year 2040, it’s estimated that more than 78 million American will be diagnosed with one of the many rheumatic diseases.

September 2017 is the second annual Rheumatic Disease Awareness Month, an initiative created by the American College of Rheumatology (ACR), to raise awareness about arthritis, lupus, gout, and more than 100 forms of rheumatic diseases. These diseases come with a price tag of more than $128 billion annually in medical expenditures. While research suggests the cause of rheumatic disease is a combination of genetic and environmental factors, the exact cause of these diseases is still unknown.

Learn more about rheumatic diseases and the Simple Tasks initiative sponsored by the American College of Rheumatology, which aims to raise awareness of the severe impact of rheumatic diseases and highlight the health care policy issues that affect patients’ ability to access high-quality care. You can get informed…and get help.

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ProAssurance Establishes the Nation’s First Academic Research Program Dedicated to Physician Wellness

ProAssurance Establishes the Nation’s First Academic Research Program Dedicated to Physician Wellness

BIRMINGHAM – ProAssurance Corporation has announced the establishment of the ProAssurance Endowed Chair for Physician Wellness at the University of Alabama at Birmingham. This academic chair is the first of its kind in the United States and demonstrates ProAssurance’s commitment to its role as a leading advocate for America’s physicians.

The initial $1.5 million gift to the UAB School of Medicine will endow an academic chair and also will support a research team dedicated to addressing health issues unique to physicians as they deal with the stress and pressures associated with providing care to their patients in today’s rapidly evolving health care environment.

As he announced the gift, ProAssurance Chairman and Chief Executive Officer Stan Starnes underscored the importance of the research that will emerge.

“Physicians have always been subject to the high levels of stress from a variety of factors such as society’s expectations for successful outcomes, the threat of litigation and the effect of their professional obligations on the quality of their lives, and their families’ lives. As medicine evolves to address the changing dynamics of health care in America, we must find ways to address these pressures,” Starnes said.

“UAB leadership is committed at the highest level to provide our physicians, residents, fellows and trainees the same type of world-class care they provide for the citizens of Alabama and beyond every day,” said UAB President Ray L. Watts. “This generous investment by ProAssurance to fund a first-of-its-kind academic chair will enable us to recruit an expert in the field of physician wellness who can implement well-designed interventions that enhance our sustainable culture of wellness and provide trainees with tools and resources to manage stress and burnout. The result will be more engaged physicians who can provide the highest-quality care to their patients.”

ProAssurance also expects to provide an additional gift of $500,000 to fund various initiatives in support of physician wellness. The company’s Chief Medical Officer, Hayes V. Whiteside, M.D., said such programs are a logical extension of ProAssurance’s role as a trusted partner with physicians and the nation’s health care community.

“Assisting physicians has always been a high priority for ProAssurance. Now more than ever, we need to ensure that today’s physicians maintain their commitment to our high calling, and that future physicians are equipped to deal with the realities of their vital chosen profession,” Dr. Whiteside said.

“We are fortunate to have some of the best physicians in America right here in Birmingham as part of our School of Medicine, and it is important that we consistently work to provide them an environment that promotes wellness opportunities to help them flourish in their field,” said Selwyn Vickers, M.D., Senior Vice President of Medicine and Dean of UAB’s School of Medicine. “Doctors who take care of themselves are better role models for their patients and for their children, have higher patient satisfaction and safety scores, experience less stress and burnout, and live longer. We are grateful to ProAssurance for their gift, which will greatly enhance our training programs and enable them to create a sustainable culture of wellness.”

In addition to the funds being committed to addressing physician wellness, ProAssurance plans to make an additional financial gift to the UAB School of Nursing to enhance the future of nursing care in Alabama. “Nurses are a crucial part of the care delivery team in our state, and their role will become increasingly important as our healthcare delivery systems expand to meet the demands that will come with the exponential growth of an aging population,” said Starnes.

“Nursing is one of the most versatile — and vital — occupations in the health care workforce, and we strive to train innovative leaders who will transform health care,” said Doreen Harper, Ph.D., Dean and Fay B. Ireland Endowed Chair in UAB’s School of Nursing. “The ever-evolving landscape of health care and the changing profile of the population demand a fundamental shift in the health care system to provide patient-centered care. More nurses will be needed to deliver primary care and community care, ensure seamless care, foster interprofessional collaboration and enable all health professionals to practice to the full extent of their education, training and competencies. This shift will result in reduced errors, increased safety and the highest-quality care for patients. We are delighted and appreciative that ProAssurance is providing this support to help us shape patient-centered health care by preparing recognized nurse leaders who excel as clinicians, researchers and educators in Alabama, nationally and internationally.”

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Public Health Warns of Increased Pertussis Cases in Alabama

Public Health Warns of Increased Pertussis Cases in Alabama

The Alabama Department of Public Health’s Immunization Division is warning citizens that pertussis cases are significantly higher in Alabama and continue to be on the rise. Immunization data reveals an increase from 113 reported cases in 2016, to 151 reported cases thus far in 2017. Pertussis cases have occurred statewide in 2017, including multiple outbreaks in Calhoun and Chambers counties.

Pertussis, also known as whooping cough, is a highly contagious respiratory notifiable disease, which begins with symptoms such as a runny nose, low-grade fever and cough. After a week or two of the illness, pertussis progresses to violent coughing, making it difficult for those infected to breathe. After fits of many coughs, people with the illness often need to take deep breaths which result in a “whooping” sound.

“Alabama is not alone in the growth of pertussis cases. Nationwide we have seen an increase in pertussis cases, and while there are several factors that could contribute to this, one generally accepted reason from the Centers for Disease Control and Prevention is that although the pertussis vaccine is effective, it tends to decrease in immunity over time,” said Dr. Karen Landers, Assistant State Health Officer. “That’s why it’s so important that we educate Alabamians on this disease and let them know how they can prevent and treat it.”

During an outbreak of pertussis, Immunization Division staff collect specimens for testing, assess vaccine status, contact persons via phone who have been in places where exposure has occurred, and provide information for entities to share with those who may have been exposed. Those who are concerned that they may have been exposed to the disease, or feel that they are exhibiting symptoms, should consult their primary physician to be evaluated.

“Patients should be aware that this is a serious disease that can affect people of all ages. It can even be deadly for babies less than a year old. That’s why it’s especially important for parents and grandparents who are in close contact with infants to make sure they are up to date on their vaccinations,” said Dr. Landers.

According to CDC, the best way to protect against pertussis is by getting vaccinated. Pregnant women should also be vaccinated with Tdap (tetanus, diphtheria, pertussis) during each pregnancy as a way to protect infants.

For more information on signs and symptoms of pertussis, or vaccination please visit and the division’s Facebook page Alabama Immunization Info at

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Study: Many Still Sidestep End-Of-Life Care Planning

Study: Many Still Sidestep End-Of-Life Care Planning

Before being deployed overseas for the Iraq War in 2003, Army reservist Don Morrison filled out military forms that gave instructions about where to send his body and possessions if he were killed.

“I thought, wow, this is mortality right in your face,” Morrison, now 70, recalled.

With his attention keenly focused on how things might end badly, Morrison asked his lawyer to draw up an “advance directive” to describe what medical care he did and did not want if he were unable to make his own decisions.

One document, typically called a living will, spelled out Morrison’s preferences for life-sustaining medical treatment, such as ventilators and feeding tubes. The other, called a health care proxy or health care power of attorney, named a friend to make treatment decisions for him if he were to become incapacitated.

Not everyone is as motivated to tackle these issues. Even though advance directives have been promoted for nearly 50 years, only about a third of U.S. adults have them, according to a recent study.

People with chronic illnesses were only slightly more likely than healthy individuals to document their wishes.

For the analysis, published in the July issue of Health Affairs, researchers reviewed 150 studies published from 2011 to 2016 that reported on the proportion of adults who completed advance directives, focusing on living wills and health care power-of-attorney documents.

Of nearly 800,000 people on whom the studies reported, 36.7 percent completed some kind of advance directive. Of those, 29.3 percent completed living wills, 33.4 percent health care proxies and 32.2 percent were “undefined,” meaning the type of advance directive wasn’t specified or combined the two.

People older than 65 were significantly more likely to complete any type of advance directive than younger ones, 45.6 percent vs. 31.6 percent. But the difference between people who were healthy and those who were sick was much smaller, 32.7 percent compared with 38.2 percent.

The Medicare program began reimbursing physicians in January 2016 for counseling beneficiaries about advance-care planning.

This study doesn’t incorporate any data from those changes. Rather, it can serve as a benchmark to gauge improvement, said Dr. Katherine Courtright, an instructor of medicine in pulmonary and critical care at the University of Pennsylvania. She is the study’s senior author.

There are many reasons that people are reluctant to sign a living will. State forms vary, but they generally ask people to spell out what medical intervention they want under various circumstances.

“Many people don’t sign advance directives because they worry they’re not going to get any care if they say they don’t want [cardiopulmonary resuscitation],” said Courtright. “It becomes this very scary document that says, ‘Let me die.’”

Living wills also don’t account for the fact that people’s wishes may change over time, said Dr. Diane Meier, a geriatrician and the director of the New York-based Center to Advance Palliative Care.

“In some ways, the public’s lack of excitement about this is related to the reality that it’s very hard to make decisions about the kind of care you want in the future when you don’t know what that will be like,” Meier said.

Sometimes as patients age and develop medical problems they’re more willing to undergo treatments they might have rejected when they were younger and healthier, Meier said.

“People generally want to live as well as they can for as long as they can,” Meier said. If that means going on a ventilator for a few days in order to get over a bout of pneumonia, for example, many may want to do that.

But if their living will says they don’t want to be put on a ventilator, medical staff may feel bound to honor their wishes. Or not. Although living wills are legal documents, medical staff and family members or loved ones can reinterpret them.

“At the moment, I’m very healthy,” Morrison said. If he were to become ill or have a serious accident, he said, he’d want to weigh life-saving interventions against the quality of life he could expect afterward. “If it were an end-of-life scenario, I don’t want to be resuscitated,” he said.

If someone’s wishes change, the documents can be changed. There’s no need to involve a lawyer in creating or revising advance directives, but they generally must be witnessed and may have to be notarized.

Although living wills can be tricky, experts have no reservations about recommending that people have a health care proxy. Some even suggest, for example, that naming someone for that role should be a routine task that’s part of applying for a driver’s license.

“Treatment directives of any kind all assume we can anticipate the future with accuracy,” said Meier. “I think that’s an illusion. What needs to happen is a recognition that decisions need to be made in real time and in context.”

That’s where the health care proxy comes in. Just naming someone isn’t enough, though. To be effective, people need to have conversations with their proxy and other loved ones to talk about their values and what matters to them at the end of life.

They may tell their health care proxy that they want to die at home, for example, or that being mobile or able to communicate with their family is very important, said Jon Radulovic, a vice president at the National Hospice and Palliative Care Organization.

Some may opt to forgo painful interventions to extend their lives in favor of care that keeps them comfortable and maintains the best quality of life for the time that remains.

“The most important thing is to have the conversation with the people that you love around the kitchen table and to have it early,” said Ellen Goodman, a Pulitzer Prize-winning writer who founded The Conversation Project, which provides tools to help people have conversations about end-of-life issues.

Morrison said he’s talked with his health care proxy about his wishes. The conversation wasn’t difficult, he said. Rather than spell out precisely what he wants done under what circumstances, Morrison is leaving most of the decisions to his health care proxy, if he can’t make his own choices.

Morrison said he’s glad he’s put his wishes down on paper. “I think that’s very important to have,” he said. “It may not be a disease that I get, it may be a terrible accident. And that’s when [not knowing someone’s wishes] becomes a crisis.”

By Michelle Andrews | Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Report: Deaths from Cancer Higher in Rural America

Report: Deaths from Cancer Higher in Rural America

Despite decreases in cancer death rates nationwide, a new report shows slower reduction in cancer death rates in rural America (a decrease of 1.0 percent per year) compared with urban America (a decrease of 1.6 percent per year), according to data released today in CDC’s Morbidity and Mortality Weekly Report. The report is part of a series of MMWR studies on rural heath.

The report is the first complete description of cancer incidence and mortality in rural and urban America. Researchers found that rates of new cases for lung cancer, colorectal cancer, and cervical cancer were higher in rural America. In contrast, rural areas were found to have lower rates of new cancers of the female breast and prostate. Rural counties had higher death rates from lung, colorectal, prostate, and cervical cancers.

“While geography alone can’t predict your risk of cancer, it can impact prevention, diagnosis and treatment opportunities – and that’s a significant public health problem in the U.S.,” said CDC Acting Director Anne Schuchat, M.D. “Many cancer cases and deaths are preventable and with targeted public health efforts and interventions, we can close the growing cancer gap between rural and urban Americans.”

In the study, researchers analyzed cancer incidence data from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program. Cancer deaths were calculated from CDC’s National Vital Statistics System. Counties were grouped by urbanization and population size.

Key findings from analysis of cancer rates

  • Death rates were higher in rural areas (180 deaths per 100,000 persons) compared with urban areas (158 deaths per 100,000 persons). Cancer deaths in rural areas decreased at a slower pace, increasing the differences between rural and urban areas.
  • While overall cancer incidence rates were somewhat lower in rural areas (442 cases per 100,000 persons) than in urban areas (457 cases per 100,000 persons), incidence rates were higher in rural areas for several cancers, including those related to tobacco use such as lung cancer and those that can be prevented by cancer screening such as colorectal and cervical cancers.
  • While rural areas have lower incidence of cancer than urban areas, they have higher cancer death rates. The differences in death rates between rural and urban areas are increasing over time.

“Cancer – its causes, its prevention, and its treatment – is complicated,” said Lisa C. Richardson, M.D., oncologist and director of CDC’s Division of Cancer Prevention and Control. “When I treat cancer patients, I don’t do it alone – other healthcare professionals and family members help the patient during and after treatment. The same is true for community-level preventive interventions. Partnerships are key to reducing cancer incidence and the associated disparities.”

The CDC researchers identify a number of proven strategies that can reduce the gaps in new cancer cases and deaths. Healthcare providers in rural areas can:

    • Promote healthy behaviors that reduce cancer risk. Prevent tobacco initiation, promote tobacco cessation, and eliminate secondhand smoke exposure. Limit excessive exposure to ultraviolet rays from the sun and tanning beds. Encourage physical activity and healthy eating to prevent and reduce obesity, which is associated with several types of cancer.
    • Increase cancer screenings and vaccinations that prevent cancer or detect it early. Recommend patients receive vaccination against cancer-related infectious diseases such as HPV and hepatitis B virus. Recommend appropriate cancer screening tests such as Pap tests and colonoscopy.
    • Participate in the state-level comprehensive control coalitions. Comprehensive cancer control programs focus on cancer prevention, education, screening, access to care, support for cancer survivors, and overall pursuit of good health.

These data from CDC provide a clear direction for the work that needs to be done to reduce cancer disparities throughout the U.S., and provide the foundation for proven strategies that could be implemented. Proven strategies to improve health-related behaviors, increased use of vaccinations that prevent infections that can cause cancer, and use of cancer screening tests – particularly among people that live in rural and underserved areas – can help reduce the rates of cancer and cancer deaths across America.

For more information on rural health:

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UPDATE: No Vote on Senate Health Care Bill Before July 4

UPDATE: No Vote on Senate Health Care Bill Before July 4

REVISED June 28, 2017: Although Senate Republicans had initially promised a vote on its “Better Care Reconciliation Act of 2017,” now it appears that will not be the case prior to the July 4 recess. With the release of the Congressional Budget Office report on the act, it did not appear there would be enough support to pass the legislation. While the bill is not dead, it appears that Senate Republican leaders want more time for discussion.

The Medical Association continues to review the legislation as proposed, remains in contact with Alabama’s Congressional Delegation, and is closely monitoring the legislation as it moves forward.

June 23, 2017: On Thursday, Senate Republicans released a draft of its version of their legislation intended to repeal and replace the Affordable Care Act. The 142-page “discussion draft,” called the “Better Care Reconciliation Act of 2017,” resembles the version passed by the House in May by repealing the ACA’s individual mandate and several taxes on the industry. However, the proposed legislation has several differences as well.

Pertaining to Medicaid:

  • Medicaid expansion is phased out from 2020 to 2024.
  • Medicaid’s funding structure would change to a per-capita arrangement, creating deep cuts in funding beginning in 2025.
  • States would be allowed to require nondisabled, nonelderly, nonpregnant participants to satisfy a work requirement for eligibility.

For the individual market:

  • Subsidies would be based on income, not age, as included in the House version, and the subsidies will be less generous being capped at 350% of the federal poverty level.
  • In 2018 and 2019 $15 billion would be set aside ($10 billion in 2020 and 2021) for health insurers to “address coverage and access disruption and respond to urgent health care needs within states.”
  • The proposed legislation sets up a “long-term state stability and innovation program,” to be funded with $62 billion over eight years.
  • States will have flexibility to opt out of the ACA’s provisions regulating individual markets by tweaking existing 1332 waivers.

The Medical Association is reviewing the legislation as proposed, remains in contact with Alabama’s Congressional Delegation, and is closely monitoring the legislation as it moves forward.

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Opioids in Alabama: Where Do We Go From Here?

Opioids in Alabama: Where Do We Go From Here?

The numbers are staggering. In 2015 alone opioid-related overdoses accounted for more than 33,000 deaths — nearly as many as traffic fatalities. Today more than 2.5 million adults in the U.S. are struggling with addiction to opioid drugs, including prescription opioids and heroin.

According to the Centers for Disease Control and Prevention:

  • About 91 Americans die every day from an opioid overdose (that includes prescription opioids and heroin)
  • Drug overdose deaths and opioid-involved deaths continue to increase in the United States
  • The majority of drug overdose deaths — more than six out of 10 — involve an opioid
  • Since 1999, the number of overdose deaths involving opioids — including prescription opioids and heroin) quadrupled
  • From 2000 to 2015 more than half a million people died from drug overdoses
  • In 2014, almost 2 million Americans abused or were dependent on prescription opioids
  • Many people receiving prescription opioids long term in primary care settings struggle with addiction, ranging from 3 to 26 percent in a review by the CDC
  • Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids

How did we get here?

In 2015, among 52,404 drug overdose deaths, 33,091 were from opioids that physicians prescribe such as hydrocodone. Studies suggest most of these involve diversion of legally prescribed pills, but some people died of the pills prescribed to them. Increasingly, as officials from the CDC recently testified before Congress, it is illicit drugs such as heroin and fentanyl that account for a rising tide of deaths.

Tracing America’s opioid epidemic goes back some experts say to the Roaring Twenties – a time when flappers danced to hot jazz, bootleggers sold black market alcohol in speakeasies run by mobsters, and morphine was handily prescribed for anxiety and depression.

“Opioids have been around for a very long time. Even back in the 1920s if you had depression or anxiety and you went to the doctor, you were likely to be prescribed a morphine-like medication,” said Daniel Doleys, PhD, clinical psychologist, director and owner of The Doleys Clinic in Birmingham. “Narcotics and opioid compounds do tend to stabilize different psychiatric problems, so oftentimes when we are prescribing these to patients, we think we are treating pain, but we may inadvertently be treating these underlying problems. The significance being that the patient may not show much improvement in pain or functioning, resulting in a lowering of the dose. This, however, can lead to re-emergence of the psychiatric symptoms and a plea from the patient and family to restore the medicine to its previous level. The potential impact of opioids on psychiatric symptoms, such as anxiety, depression, bipolar disorder, PTSD, and how this relates to the prescribing and overuse of opioids has not gotten much attention.”

According to Dr. Doleys, the altruistic nature of medicine itself could be one of the primary factors involved in today’s opioid crisis. Physicians are trained in the healing arts and simply want to heal their patients.

“You cannot cure suffering, and that’s part of the problem. You have a lot of well-intended clinicians who feel their job is to cure suffering. But, you cannot cure all suffering,” Dr. Doleys explained. “A certain amount of suffering is not necessarily a bad thing. It motivates us; it drives us. In our attempt to try to cure suffering, we have become co-dependent with the patient and taken their problem and made it our problem. So, we’ve communicated with the patient that I have something here that I’m going to give you. We will start with two of these pills a day. It may or may not be enough, but we’ll see. The message to the patient may be, if two isn’t enough, we can increase the dose. The often unrecognized position assumed by the well-meaning doctor is that I’m committed to saving this patient from suffering, and if this patient is still suffering, then I need to keep going until I find a cure.”

More emphasis needs to be placed on clarifying expectations, goals and patient responsibilities as it relates to their treatment. All too often patients are allowed to become ‘passive recipients rather than active participants’ in their treatment, according to Dr. Doleys.

What is so special about opioids?

In 1986, pain specialists Russell K. Portenoy and Kathleen M. Foley published “Chronic Use of Opioid Analgesics in Non-Malignant Pain: Report of 38 Cases” in the journal Pain.

“We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse,” the authors wrote.

Dr. Doleys said of the study that with 67 percent of patients reporting a fairly good outcome with little adverse effects, although at doses much smaller than we typically see today. The study became “the lightbulb” that began a trend for opioids, which were originally prescribed only for malignant pain, to be used with other types of chronic pain.

“Questions soon began about how our bodies have these receptors which we already know will react to specific medications. We have these medications, but we are not helping people who are suffering and dying with pain,” Dr. Doleys said. “There was an increased awareness of people in pain from other sources rather than cancer, and the concerns began to grow about the under-treatment of pain, and some concerns were valid and almost criminal.”

In the 1980s, physicians began facing mounting pressures from not only their patients who were suffering from chronic pain issues, but also from advocacy groups and the federal government over the under-treatment of pain as a serious medical issue. By this time, there were about 100 million Americans reportedly suffering from chronic pain-related issues, according to the Institute of Medicine. With advertisements blasting away on television further advocating for the treatment of pain and applying even more pressure to the medical community to aggressively treat chronic pain, physicians were caught in the middle.

Pharmaceutical companies saw an opportunity and began producing more and more opioid medications, touting these new medications to physicians and federal regulatory boards as being safer than other painkillers on the market at that time. Unfortunately, this was not the case. When the dust settled and some of these companies were brought to court over their false advertising claims, millions of patients were addicted to their products.

Where the pendulum of prescribing opioids once swung toward over-treating chronic pain issues is now swinging back in a new direction, new issues are being uncovered – specifically addiction.

How opioids kickstarted the national conversation of addiction

“There is one positive outcome of the opioid epidemic. It has raised the awareness and acknowledgment that addiction is a disease. A national conversation has been initiated as a result of the severity, morbidity and mortality associated with opioid misuse and addiction,” explained addiction medicine specialist James Harrow, M.D., PhD. “We have been reluctant to acknowledge that addiction is a chronic, primary brain disease as opposed to what many people still believe is a voluntary process and that sufferers can just stop. That’s not the way it works. It is a biopsychosocial-spiritual disease that is chronic, relapsing and potentially lethal.”

According to Dr. Harrow, addiction is no different than other chronic diseases such as diabetes, asthma or hypertension. Addiction is preventable and when a patient has the illness, it is treatable with resultant long-term abstinence and remission. Those who are affected will be at risk of relapse to their drug of choice or other substances including alcohol for their lifetime. One of the problems we encounter is that addiction medicine is not taught in medical school.

“Medical education provides little to no training for what is probably the most prevalent disease in our nation today,” Dr. Harrow said. “The teaching of addiction is beginning to develop gradually within medical schools. However, if we do not educate medical students early in their training, then it is more difficult to assimilate the understanding of the disease when they enter practice.”

As with any other disease, physicians are not immune to the disease of addiction. Looking at the national population of physicians in the United States, roughly 900,000 doctors, the lifetime prevalence of addiction of practicing physicians is around 15 percent or about 135,000, Dr. Harrow said.

“Physicians may see themselves as superhuman, but that’s not the case. They may not be able to see themselves as being able to have these diseases, but they can and do,” Dr. Harrow said.

Because physicians face the same diseases as the patients, including addiction, that’s where the Alabama Physician Health Program steps in. APHP was created by the Alabama Legislature as a means for the Alabama Board of Medical Examiners and the Medical Association to address problems such as chemical dependence or abuse, mental illness, personality disorders, disruptive behaviors, sexual boundaries, etc. All information is privileged and confidential. The success rate of APHP for five years of monitoring is 85-90 percent with physicians successfully returning back to practice versus the long-term success rate of other programs of about 60 percent.

A clinical tool to aid in the war on opioid abuse

The Prescription Drug Monitoring Program is housed in the Alabama Department of Public Health and developed to detect diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act. Under the Code of Alabama, 1975, § 20-2-210, et.seq, ADPH was authorized to establish, create and maintain a controlled substances prescription database program. This law requires anyone who dispenses Class II, III, IV and V controlled substances to report the dispensing of these drugs to the database.

Mandatory reporting began April 1, 2006. For those physicians who are eligible to use the PDMP, but are not yet registered, access is easy. Registering to access the PDMP database can be done by:

  • Go to
  • Click on PDMP Login found in the orange menu banner on the left
  • Click on Practitioner/Pharmacist
  • Click on Registration Site for New Account
  • Enter newacct for the User Name and welcome for the Password
  • Complete the registration form and click on Accept and Submit

You will receive two emails when your application is approved; one with your user name and a second with a temporary password. Each physician can designate two delegate users per office. These delegate users have their own usernames and passwords to access the PDMP system.

If you have trouble using the PDMP, help is at your fingertips. Assistance with passwords, connection issues, search and query issues, and most other PDMP problems is just a phone call away at (855) 925-4767 and follow the prompts or by email at

The Alabama PDMP anticipates switching to new software later this year. The new software is user-friendly and has additional features that will aid prescribers and dispensers in making the best clinical decisions for their patients. More information about training will be emailed to users in the coming months.

Where do we go from here?

It would seem there’s a story on the news every day about opioid abuse. A new statistic, a new arrest, a new death toll, yet no new solutions even though every state and every organization has a task force or study group working on the nation’s epidemic.

Stefan Kertesz, M.D., MSc, is associate professor at the University of Alabama-Birmingham School of Medicine and director of the Homeless Patient-Aligned Care Team at the Birmingham Veterans Affairs Medical Center. His 20-year career has combined research and clinical care focused on primary and addiction care of vulnerable populations with funding from the National Institute on Drug Abuse and the U.S. Department of Veterans Affairs. In 2016, he provided peer-reviewed and public media reviews of several facets of the opioid crisis, the rise of illicit fentanyl and heroin deaths, and how new policies affect patients with pain conditions. He may not have any new solutions, but his close study of the opioid epidemic has uncovered some interesting insights.

“We as doctors played a significant role in developing the opioid market, even though at this point we’re not the ones sustaining it,” Dr. Kertesz said.

In fact, one of Dr. Kertesz’s chief concerns stems from the revised CDC Guideline for Prescribing Opioids for Chronic Pain, issued in March 2016, which might have caused a “pendulum swing” from the status quo of prescribing of opioids for chronic pain to a stricter guideline for their use. The CDC Guideline provides recommendations for primary care physicians who are prescribing opioids for chronic pain outside cancer treatment, palliative care and end-of-life care. This pendulum swing toward an effort to curb prescribing habits might be putting more patients at risk than physicians might know.

“As physicians today execute a hard shift on opioids, I plead for caution,” Dr. Kertesz said. “Patients with chronic pain have reported enormous suffering, some committing suicide as they see their lives turned upside down by doctors pressured to reduce their medications. Opioid prescribing ran up even more because of the use of the pain score…a subjective single number. Now there is an emergence of academic physicians who have dedicated their work to fighting addiction, including some who even worked on the CDC Guideline. They see that clinical practice has sprung ahead of data, that it has begun to look like someone has shouted fire in a crowded theater, creating a social stampede. This does not reflect the cautious, patient-centered care urged by the CDC.”

Dr. Kertesz is not advocating a return to the old days of prescribing opioids. Far from it. He works in Jefferson County, one of Alabama’s hardest hit counties where deaths by heroin, fentanyl and other prescription medications are disturbingly high. In fact, he’s doing everything he can, short of shouting from the rooftops, to inform government officials and colleagues about changing the opioid epidemic. He’s written opinions and reports for STATNews, Pain News Network, Huffington Post, and Politico. He’s given interviews for state and national news agencies. He’s published numerous peer-reviewed papers and articles. And, earlier this year, he issued a briefing for Surgeon General Vivek Murthy. The message should be clear: We need a better message.

“Saying that opioids are just as addictive as heroin is fantasy, the same as solving opioid overdoses in doctors’ offices alone when most individuals with opioid addiction did not start out as pain patients,” Dr. Kertesz explained. “When Surgeon General Dr. Vivek Murthy made an under-appreciated declaration that we cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications, as an addiction professional, I agree.”

How the Medical Association continues to be a leader in the fight against Alabama’s prescription drug abuse epidemic

In Alabama, our situation is equally staggering. According to the Alabama Department of Public Health, 762 Alabama residents died between 2010 and 2014 due to drug overdose, which included prescription drug overdose. In 2014 alone, there were 221 deaths due to drug overdoses.

“A group of us from the Medical Association met with some DEA officials and sheriffs who told us that Alabama was number one for hydrocodone until 2001,” said Association President Jerry Harrison. “We fell out of the top slot for a few years, but we got it back. We recognized that Alabama was in a very bad place, and we knew we had to take action.”

The Medical Association helped pass legislation in 2013 to reduce prescription drug abuse and diversion. That legislation resulted in Alabama having the largest decrease in the southeast and third-largest in the nation regarding the use of the most highly-addictive prescription drugs.

In 2016 the Medical Association launched a new public awareness campaign called Smart & Safe, which is the only prescription drug awareness program in Alabama spearheaded by physicians. Smart & Safe promotes safe prescription use, storage and disposal of medication by providing helpful tips, news and educational opportunities online at

Last year, the American Medical Association also partnered with the Medical Association to create a new clinical tool in the fight against prescription drug abuse. The collaboration produced Reversing the Opioid Epidemic in Alabama: A Health Care Professional’s Toolbox to Reverse the Opioid Epidemic, a downloadable document housed on the Smart & Safe website, contains handy reminders about Alabama law pertaining to prescribing opioids, tips for disposal of medication, statistics and useful links.

“When we started the prescribing lectures, we encouraged physicians to prescribe dangerous combinations less. We discussed the impact of the combination of pain medications and nerve medications because adding together one and one does not equal two…one and one can equal three or four in the damage or the potential damage they do to the patients. We have presented this course to almost 5000 prescribers now, and we’ve had an impact there,” Dr. Harrison said.

This year marks the ninth year of the Association’s Prescribing courses. By the end of the year, the Association will have completed 31 courses, and until 2013 Alabama was one of the only states offering an opioid prescribing education course when the FDA developed the blueprint for Risk Evaluation and Mitigation Strategies for producers of controlled substances.

“We have to as a medical profession realize what we were taught 18-20 years ago, that we were not adequately treating pain and to increase the dosage of the pain medicine until there is a side effect, is no longer adequate. When you wake up in the morning and the first thing you think about should not be to reach for your pain tablet before you have your breakfast because you have to get going. I often wonder just what’s causing your pain first thing in the morning?” Dr. Harrison questioned. “You have to question your patients and be honest with them: Is that your pain talking, or is that your opioid rebound pain? When you and your patients start to look at that from a different point of view, then you can work together to decrease the amount of opioids used. Life is not pain-free, and opioids are not a cure for pain. It’s like licking the red off your candy. You’re making it so that the pain medicine doesn’t work for you as well as it used to. The more you take now, the less it’s going to work for you in the future. We’re part of the problem. And, if we’re part of the problem, we should be part of the solution.”

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Today is National Call Your Doctor Day!

Today is National Call Your Doctor Day!

Today is the day a woman can do one thing for herself that will take less time than tying her shoes…call your doctor and schedule your annual wellness exam. Today is National Call Your Doctor Day!

Making this day halfway through the year holds significance because so many women delay their routine care. Often placing the priorities of work, family members or other obligations before their health, women overlook the simple phone call that may save their life.

According to a 2015 survey by ZocDoc, 80 percent of Americans delay or forgo preventative care. The number increases to 93 percent when surveying Millennials.

National Call Your Doctor Day can set an example for other women, help establish a baseline for many health concerns later in life, and improve opportunities for identifying risk factors. By making the appointment and keeping it, you place a priority on staying healthy so you can continue to meet those important obligations in the future. It only takes a few minutes to commit to this one annual exam. You know people who have made more binding commitments in less time. This is one appointment you will want to keep and mark on the calendar again next year.

There may be an even quicker way to make the appointment than picking up the phone when you have an established a relationship with a physician. With many clinics, you can set up an appointment online, quickly and securely.

Call your doctor and make an appointment for a Well-Woman Exam. Encourage your friends and family to do the same by using #CallYourDoctorDay to share on social media.

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Law Allows Alabama Students to Apply Sunscreen at School

Law Allows Alabama Students to Apply Sunscreen at School

A new law allows Alabama school students to apply personal sunscreen at school without the need for special permission from a doctor or parent. The law includes public and private schools and went into effect immediately.

“Students will now be able to apply sunscreen to protect themselves from sunburn before going outside. We know that sunburn, particularly in childhood, increases your risk of skin cancer. Applying sunscreen before outside school activities will prevent overexposure to the sun’s UVA and UVB rays, thus preventing many forms of skin cancer, including melanoma, the deadliest form of skin cancer,” Dr. Tom Miller, State Health Officer at the Alabama Department of Public Health, said.

According to the Centers for Disease Control and Prevention, application of sunscreen while outdoors is a simple step to protect yourself from the harm of overexposure to sunlight’s UVA and UVB rays. A sunscreen with an SPF of 30 or higher should be applied at least every two hours, especially after swimming or sweating. For parents with babies less than 6 months old, please follow directions on the sunscreen’s package for its use.

Aside from sunscreen, other steps to protection from the sun’s harmful UV rays include the following:

  • Avoiding use of sunbathing and tanning beds
  • Covering up with protective clothing and wide-brimmed hats
  • Seeking shade, especially during midday hours (between 10 a.m. and 4 p.m.)

Previously, students were unable to use sunscreen unless prescribed by a physician. With the passage of this law, no rules of the State Board of Education or the Alabama Board of Nursing will apply to Food and Drug Administration-approved over-the-counter sunscreen.

Melanoma is the most commonly diagnosed cancer in the U.S. and is responsible for about 78 percent of all skin cancer deaths. Melanoma occurs when the pigment-producing cells that give color to the skin become cancerous. Cases of melanoma are 6 percent higher in Alabama than the national average. It is the most common type of skin cancer in children.

Alabama is among a growing number of states — like Arizona, California, New York, Oregon, Texas, Utah and Washington State — that lawfully permit students’ use of sunscreen at school.

For more information about sun safety, visit or

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Public Restrooms Become Ground Zero in the Opioid Epidemic

Public Restrooms Become Ground Zero in the Opioid Epidemic

A man named Eddie threaded through the midafternoon crowd in Cambridge, Mass. He was headed for a sandwich shop, the first stop on a tour of public bathrooms.

“I know all the bathrooms that I can and can’t get high in,” said Eddie, 39, pausing in front of the shop’s plate-glass windows, through which we can see a bathroom door.

Eddie, whose last name we’re not including because he uses illegal drugs, knows which restrooms along busy Massachusetts Avenue he can enter, at what hours and for how long. Several restaurants, offices and a social services agency in this neighborhood have closed their restrooms in recent months, but not this sandwich shop.

“With these bathrooms here, you don’t need a key. If it’s vacant, you go in. And then the staff just leaves you alone,” Eddie said. “I know so many people who get high here.”

At the fast-food place right across the street, it’s much harder to get in and out.

“You don’t need a key, but they have a security guard that sits at the little table by the door, directly in front of the bathroom,” Eddie said. Some guards require a receipt for admission to the bathroom, he said, but you can always grab one from the trash.

A chain restaurant a few stores down has installed bathroom door locks opened by a code that you get at the counter. But Eddie and his friends just wait by the door until a customer goes into the restroom, then grab the door and enter as the customer leaves.

“For every 10 steps they use to safeguard against us doing something, we’re going to find 15 more to get over on their 10. That’s just how it is. I’m not saying that’s right, that’s just how it is,” Eddie said.

Eddie is homeless and works at a restaurant. Public bathrooms are among the few places where he can find privacy to inject heroin. He says he doesn’t use the drug often these days. Eddie is on methadone, which curbs his craving for heroin, and he says he now uses the drug only occasionally to be social with friends.

He understands why restaurant owners are unnerved.

“These businesses, primarily, are like family businesses; middle-class people coming in to grab a burger or a cup of coffee. They don’t expect to find somebody dead,” Eddie said. “I get it.”

Managing Public Bathrooms Is ‘A Tricky Thing’

Many businesses don’t know what to do. Some have installed low lighting — blue light, in particular — to make it difficult for people who use injected drugs to find a vein.

The bathrooms at 1369 Coffee House, in the Central Square neighborhood of Cambridge, are open for customers who request the key code from staff at the counter. The owner, Joshua Gerber, has done some remodeling to make the bathrooms safer. There’s a metal box in the wall next to his toilet for needles and other things that clog pipes. And Gerber removed the dropped ceilings in his bathrooms after noticing things tucked above the tiles.

“We’d find needles or people’s drugs,” Gerber said. “It’s a tricky thing, managing a public restroom in a big, busy square like Central Square where there’s a lot of drug use.”

Gerber and his staff have found several people on the bathroom floor in recent years, not breathing.

“It’s very scary,” Gerber said. His eyes drop briefly. “In an ideal world, users would have safe places to go [where] it didn’t become the job of a business to manage that and to look after them and make sure that they were OK.”

There are such public safe-use places in Canada and some European countries, but not in the U.S., at least not yet. So Gerber is taking the unusual step of training his baristas to use naloxone, the drug that reverses most opioid overdoses. He sent a training invitation email to all employees recently. Within 10 minutes, he had about 25 replies.

“Mostly capital ‘Yes!! I’ll be there for sure!’ ‘Count me in!’” Gerber recalled with a grin. “You know, [they were] just thrilled to figure out how they might be able to save a life.”

Safe Spaces and Hospital Bathrooms

Last fall, a woman overdosed in a bathroom in the main lobby of Massachusetts General Hospital in Boston. Luckily, naloxone has become standard equipment for security guards at many hospitals in the Boston area, including that one.

“I carry it on me every day, it’s right here in a little pouch,” said Ryan Curran, a police and security operations manager at the hospital, pulling a small black bag out of his suit jacket pocket.

The woman who overdosed survived, as have seven or eight people who overdosed in the bathrooms since Curran’s team started carrying naloxone in the past 12 to 18 months.

“It’s definitely relieving when you see someone breathing again when two, three minutes beforehand they looked lifeless,” Curran said. “A couple of pumps of the nasal spray and they’re doing better. It’s pretty incredible.”

Massachusetts General Hospital began training security guards after emergency room physician Dr. Ali Raja realized that the hospital’s bathrooms had become a haven for some of his overdose patients.

“There’s an understanding that if you overdose in and around a hospital that you’re much more likely to be able to be treated,” Raja said, “and so we’re finding patients in our restrooms, we’re finding patients in our lobbies who are shooting up or taking their prescription pain medications.”

Many businesses, including hospitals and clinics, don’t want to talk about overdoses within their buildings. Curran wants to be sure the hospital’s message about drug use is clear.

“We don’t want to promote, obviously, people coming here and using it, but if it’s going to happen, then we’d like to be prepared to help them and save them and get them to the [Emergency Department] as fast as possible,” Curran said.

Speed is critical, especially now, when heroin is routinely mixed with the much more potent opioid, fentanyl. Some clinics and restaurants check on bathroom users by having staff knock on the door after 10 or 15 minutes, but fentanyl can deprive the brain of oxygen and cause death within that window. One clinic has installed an intercom and requires people to respond. Another has designed a reverse-motion detector that sets off an alarm if there’s no movement in the bathroom.

Limited Public Discussion

There’s very little discussion of the problem in public, says Dr. Alex Walley, director of the Addiction Medicine Fellowship Program at Boston Medical Center.

“It’s against federal and state law to provide a space where people can use [illegal drugs] knowingly, so that is a big deterrent from people talking about this problem,” he said.

Without some guidance, more libraries, town halls and businesses are closing their bathrooms to the public. That means more drug use, injuries and discarded needles in parks and on city streets.

In the area around Boston Medical Center, wholesalers, gas station owners and industrial facilities are looking into renting portable bathrooms.

“They’re very concerned for their businesses,” said Sue Sullivan, director of the Newmarket Business Association, which represents 235 companies and 28,000 employees in Boston. “But they don’t want to just move the problem. They want to solve the problem.”

Walley and other physicians who work with addiction patients say there are lots of ways to make bathrooms safer for the public and for drug users. A model restroom would be clean and well-lit with stainless-steel surfaces, and few cracks and crevices for hiding drug paraphernalia. It would have a biohazard box for needles and bloodied swabs. It would be stocked with naloxone and perhaps sterile water. The door would open out so that a collapsed body would not block entry. It would be easy to unlock from the outside. And it would be monitored, preferably by a nurse or EMT.

There are Very Few Bathrooms that Fit this Model in the U.S.

Some doctors, nurses and public health workers who help addiction patients argue any solution to the opioid crisis will need to include safe injection sites, where drug users can get high with medical supervision.

“There are limits to better bathroom management,” said Daniel Raymond, deputy director for policy and planning at the New York-based Harm Reduction Coalition. If communities like Boston start to reach a breaking point with bathrooms, “having dedicated facilities like safer drug consumption spaces is the best bet for a long-term structural solution that I think a lot of business owners could buy into.”

Maybe. No business groups in Massachusetts have come out in support of such spaces yet.

By Martha Bebinger, WBUR | This story is part of a partnership that includes WBUR, NPR and Kaiser Health News. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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