March/2016
Issue: 50

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Fiftieth Issue: March Madness
While recent primary results show that there is a madness gripping our beloved land, there is some comfort in knowing that Villanova is in the Final Four! Go Wildcats!! After that, I am prescribing frequent attendance at baseball games. Listen to the famous George Carlin baseball vs footfall monologue captured on YouTube. You will feel better and understand why baseball could be the remedy for what ails us!!

John A. Schmidt, MD 
Internist
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Uber and Lessons for Healthcare
Many of us have had the pleasure of using our smart phones to summon an Uber cab any time of the day or night. As discussed in an interesting editorial in the March 3 issue of the New England of Medicine, Uber deftly broke into a highly regulated industry and affected a paradigm shift. The key to their success was improved service and most would agree, myself included, that medicine should take a page out of their playbook. Are minute clinics the medical equivalent of Uber? Yes, because they provide fast service. No, because they provide service without access to your PHI (personal health information). Conversely, Emergency Departments may have access to your PHI but are very slow, not to mention expensive. Clinicians in both settings usually conclude the encounter by saying, "Make sure you call your primary care physician."

Add my cell phone number ((908) 256-9439) to your cell phone directory. I have Internet access to your PHI and can often save you time if you call or text me with your concerns. You can speed the process by gathering some simple information beforehand. Information such as body temperature, blood pressure, oxygen saturation, and urine test results often allow me to recommend a solution quickly. The service is free. And now that Ms. Monica Clark, a certified physician assistant (PA-C), has joined my practice, we plan to be even more responsive to your needs and offer a same day appointment if indeed that is what you need. Uber we are not. But with your help, we hope to provide a timely Uber-like experience most of the time.
Menopause Management
As discussed in an editorial in the March 3 issue of the New England Journal of Medicine, irrational fears surrounding hormone replacement therapy (HRT) have led to under-treatment of women afflicted with moderate to severe menopausal symptoms. These fears are largely due to misinterpretation of the famous Women's Health Initiative trial which highlighted the risks of HRT in elderly women or women who have been on HRT for more than five years. Clearly, the "baby was thrown out with the bathwater" because HRT continues to be the best treatment of menopausal symptoms in women who have no contraindications to such therapy. A free app from the North American Menopause Society called MenoPro helps physicians and patients weigh the benefits and the risks. Down load it today or visit the Healthy Links page at SchmidtMd.com.
 
The authors also point out that vulvo-vaginal atrophy occurs in up to 45% of women in midlife or later, adversely affecting physical and sexual health and quality of life. Despite compelling evidence that low-dose vaginal estrogen (e.g. Estrace vaginal cream) is safe and effective, the condition is substantially under-treated.
 
This gap in care has unfortunately led compounding pharmacies to offer a plethora of "bio-identical" hormone treatments below the radar of the FDA. Simply put, there is no need to resort to formulations that have not been approved by FDA. There are many excellent, FDA-approved, products including trans-dermal preparations, many of which enjoy insurance coverage. Let me or your GYN know if we can help.
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Substance Use Disorders
Patients ask me if they have a substance use disorder. (Notice, I did not say "abuse" or "addiction.") A good approach to answering this question can be found at SAMHSA.gov, the Substance Abuse and Mental Health Services Administration website. SAMHSA discusses substance use disorders related to alcohol, tobacco, cannabis (marijuana), stimulants (amphetamine), hallucinogens (LSD), and opioids and also provides a locator for substance use and mental health services at findtreatment.samhsa.gov. Characteristics common to all substance use disorders include craving, inability to abstain even for short periods of time, continued use despite interference with work, school, home or social obligations, use of larger amounts over time, development of tolerance and/or disability, willingness to take unreasonable risks to obtain access, and withdrawal symptoms. Severity is based on the number of criteria met. 
CDC Issues Guideline on Opioid Prescribing
Today, St. Joseph's Hospital in Patterson, New Jersey, was the first in the nation to report that it would no longer prescribe narcotic analgesics in its Emergency Department

Given the sharp national rise in heroin deaths, the Centers for Disease Control (CDC) has ventured into new territory and on March 15 issued guidelines for opioid prescriptions by primary care clinicians. The guidelines are not meant to apply to opioid prescriptions written for patients with cancer or in palliative or hospice care. As described in the editorial in the Journal of the American Medical Association on the same date, more than 10 million Americans reported using opioids for non-medical reasons in 2014! Four of five persons newly initiating heroin, reported starting with a prescription opioid. In 2012, U.S. health care practitioners wrote more than 200 million prescriptions for opioids, double the number in 1998! The steady growth in narcotic prescriptions is due in part to physicians and dentists reacting to accusations in the 1990's that they were insensitive to patient pain.
 
Here are the highlights of the CDC recommendations:
 
1. Non-opioids are preferred for chronic pain management. These would include acetaminophen, NSAIDs, gabapentin (Neurontin), pregabalin (Lyrica), amitriptyline (Elavil), and duloxetine (Cymbalta).
 
2. When prescribing opioid therapy, clinicians should prescribe immediate-release opioids (tramadol, oxycodone, hydrocodone) instead of extended-release/long acting (ER/LA) opioids such as Oxycontin. Use of immediate and extended release opioids in combination is discouraged.
 
3. When prescribing opioids for short term pain (e.g. carpal tunnel, dental extraction), limit duration to three days and limit the strength to the lowest dose required to mitigate the pain.
 
4. Avoid concurrent use with benzodiazepines (clonazepam, alprazolam, etc.) whenever possible.
 
5. Review patient opioid prescription history using the states prescription monitoring program (PDMP) data. Your pharmacist and I have access to the New Jersey Prescription Monitoring Program data base in Trenton. Patients receiving opioids from more than one prescriber on a regular basis will generally be denied a new prescription.
 
6. Offer buprenorphine or methadone to patients with Opioid Use Disorder.
 
Opioid use disorder is unfortunately widespread and does not discriminate on the basis of gender, age, socioeconomic, educational, or ethnic background. Let's work together to minimize opioid use. Keep your opioids in a safe place and do not share with others! Use them no longer than absolutely necessary and transition to non-opioids.
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Tobacco Use Disorder: Gradual Versus Abrupt Smoking Cessation
So many of my smokers defend their tobacco use disorder by saying, "I cut back," and then never succeed in stopping. As published in the March 15 issue of the Annals of Internal Medicine, quitting abruptly was a significantly more successful strategy!
Physical Fitness and Type 2 Diabetes
As reported in the March 15 issue of the Annals of Internal Medicine, physical inactivity is an important risk factor for type 2 diabetes mellitus. This Swedish study followed 1.5 million male military recruits, none of whom had diabetes at baseline. Those with both low cardiopulmonary and muscular fitness at age 18 were three times more likely to develop DM later in life, independent of body mass index! Other studies show the same inverse relationship with all-cause mortality! Similar trends also hold in those with diabetes! The editorialist concludes by saying, "Taken together, good evidence shows that physical fitness is an important health-enhancing trait across the spectrum of diabetes progression and weight status." I encourage you and the ones you love to participate in cardio and strength building activities regardless of your weight and age, whether or not you have diabetes and especially if you have pre-diabetes! You will add quality years to your life!  
Treatment of Uncomplicated Skin Abscess
Incision and drainage (I&D) has been the standard of care in treating skin abscesses. U.S. emergency department visits for cutaneous abscess have increase with the emergence of methicillin-resistant staphylococcus aureus (MRSA). In a study published in the March 3 issue of the New England Journal of Medicine, treatment with double strength trimethoprim-sufamethoxazole (Bactrim-DSR ) after I&D resulted in a significantly higher cure rate. Interestingly, the need for second procedures, skin infections at new sites, and infections in household members were also reduced. Thus, if you have a boil in need of drainage and you have no allergy to sulfa, ask for a prescription for Bactrim-DS (or its generic equivalent) and take the medicine with food (not alcohol) twice a day for seven days to get the best results for you and your family.  
Now Hear This!
Ms. Monica Clark has begun to see patients and early feedback has been uniformly positive! Keep in mind that all charts come to me for sign-off. This way you get the benefit of two experts while I keep abreast of your progress. Ms. Clark can be reached through our main number (732-282-8166) during working hours. You can also leave her messages at that number during off-hours. All messages left with the answering service will be sent directly to me.
 
Valerie, Morgan, Ms. Clark and I wish you a sane and pleasant Spring!
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In This Issue
March Madness
Uber and Lessons for Healthcare
Menopause Management
Substance Use Disorders
CDC Issues Guideline on Opioid Prescribing
Tobacco Use Disorder
Physical Fitness and Type 2 Diabetes
Treatment of Uncomplicated Skin Abscess
Now Hear This
  
John A. Schmidt Jr., M.D.
Board Certified Internist
 
Dr. Schmidt is one of the leading internists in Monmouth County offering Medical Home services.  

He is an Associate Attending in the Department of Medicine, Jersey Shore University Medical Center, and  Clinical Assistant Professor in the Department of Medicine, Rutgers Robert Wood Johnson Medical School.

  
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Ms. Monica Clark Certified Physician Assistant
John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
709 Seventh Avenue
Belmar, NJ 07719
 
Phone:  732-282-8166  
Fax:  732-280-0147 
  
  
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.