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RHODE I S LA N D
M E D I C A l Jo u r n a l
SPECIAL SECT ION
O B STE TRICS / G Y N E COL OGY
G u est e d itor : R o x anne V rees , M D
O C TO BER 2 0 1 8 VOLUM E 101 • NUM BE R 8 ISSN 2327-2228
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21 The Obstetrician/Gynecologist (OB/GYN):
Revisiting the Past, Exploring the Present
and Preparing for the Future
Roxanne Vrees, MD
Guest Editor
R Vrees, MD
23 Prison: Pipeline to Women’s
Preventative Health
Luwam Ghidei, MD
Sebastian Z. Ramos, MD
E. Christine Brousseau, MD, MPH
Jennifer G. Clarke, MD, MPH
27 Perspective: Current Threats
J. Clarke, MD C. Brousseau, MD to Contraceptive Access
Leanne Free, MD
Kathleen Cohen, MD Cover image: CDC/Public Health
Rebecca H. Allen, MD, MPH Images Library
30 The Fourth Trimester of Pregnancy:
Committing to Maternal Health
and Well-Being Postpartum
Bridget Spelke, MD
Erika Werner, MD, MS
E. Werner, MD
34 On the Future of Maternal Mortality
Review in Rhode Island
Bridget Spelke, MD
Sebastian Ramos, MD
Hope Yu, MD
Michael Cohen, MD
Tanya L. Booker, MD
37 A Melting Pot of Medical Education:
Challenges, solutions, and opportunities
for improving trainee feedback and
education in the ED
Merima Ruhotina, MD
Dayna Burrell, MD
3
RHODE I S LA N D
M E D I C A l Jo u r n a l
8 C OMMENTA RY
The why of neurological
reflexes
Joseph H. Friedman, MD
The Location of the
Aronson Tree
Sutchin R. Patel, MD
Anthony A. Caldamone, MD
1 2 P ERSP EC TIV E
Is importation of drugs
from Canada the answer?
Kelly Orr, PharmD
Rita Marcoux, MBA, RPh
The Long Birth and Short
Life of The Recovery
Navigation Program
Otis U. Warren, MD
2 0 RIMJ Around
the World
Addis Ababa, Ethiopia
6 2 RIMS NeW S
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RHODE I S LA N D
M E D I C A l Jo u r n a l
In the news
Miriam Hospital 68 74 Swim Across America
receives $9.4M grant for antibiotics raises more than $220,000 to benefit
resistance research center women’s cancer research at W&I
JWU, URI 69 75 Zero Suicide initiative
now offering dual degree program in Washington County
in PharmD, PA studies receives $2M
Miriam, Project Weber/RENEW, RIPHI 71 75 Julian Fisher, MD, Exhibit
partnership receives $2.5M to address Trapped in the Middle:
substance use among gay/bisexual men The Effect of Income and
Health Inequality on the
RIDOH Health Equity Summit 72 Middle Class in America
focuses on building healthy and
resilient communities
P eop le/ P LA C ES
Jeremiah D. Schuur, MD 77 80 Abdul Saied Calvino, MD
to head emergency receives national award for work
medicine at Lifespan, Brown on decreasing cancer care disparities
Sharon Marable, MD 77 80 Abdul Saied Calvino, MD
joins Southcoast to be initiated as a Fellow of the
Physicians Group American College of Surgeons
Gofran Tarabulsi, MD 77 81 Margaret Howard, PhD
joins Center for Obstetric honored by American
and Consultative Medicine Psychological Association with
at Women & Infants 2018 Leadership Award
Maureen Phipps, MD 78 81 CharterCARE Provider Group
named president-elect of of RHODE ISLAND
American Gynecological awarded highest recognition by APG
and Obstetrical Society
81 Timothy Boardman, MD
Bob Dyer, MD 78 Cameron Gettle, MD
named to South County receive EMRA awards
Health Board of Trustees
82 Obituaries
Malavika Prabhu, MD 78 Wilma Sylvia (Friedman) Rosen, MD
maternal-fetal medicine Bernard P. St. Jean, MD
specialist joins W&I
5
OCTOBER 2018
VOLUME 101 • NUMBER 8 RHODE I S LA N D
p u b l is h er
M E D I C A l Jo u r n a l
R h o d e Isla n d Medica l Society
P resi d ent
P e t e r A. H ollma n n , MD
P resi d ent - e l ect
NOR M AN M. G OR D ON, MD
V ice presi d ent
Chr i s t in e Br ou ssea u , MD C ontri b u tions
S ecretary 41 A Nearly 50% Decrease in New HIV Diagnoses
Chr i s t in e Brou ssea u , MD
in Rhode Island from 2006–2016:
T reas u rer
T H O M AS A. BLED SOE, MD
Implications for Policy Development and Prevention
Philip A. Chan, MD, MS
I mme d iate past presi d ent
Bra dl e y J. C ollin s, MD Madeline C. Montgomery, MPH
E x ec u tive Director
Theodore Marak, MPH
N e w e ll E. Wa rde, PhD Thomas Bertrand, MPH
Timothy Flanigan, MD
E d itor - in - C h ie f Antonio Junco Fernández, MD
J o s e ph H . Fr iedma n , MD Nicole Alexander-Scott, MD, MPH
A ssociate e d itor Joseph M. Garland, MD
K e n n e t h S. Korr, MD
Amy S. Nunn, ScD
P u bl ication S taf f 46 Instability in Insurance Coverage:
M ana g in g e d itor The Impacts of Churn in Rhode Island, 2014–2017
M ary Korr
Ingrid Brugnoli-Ensin, BS, BA
m k o r r @ r i med.o rg
Jessica Mulligan, PhD
Grap h ic d esi g ner
M ar i an n e Migl iori 50 Financial Implications of Physician Specialty Choice
A d vertisin g A d ministrator Adam E. M. Eltorai, PhD
S ar ah Brook e St even s
Ashley Szabo Eltorai, MD
sst e v e n s@ ri med.o rg
Carolina Fuentes, BS
Wesley M. Durand, BS
Alan H. Daniels, MD
Shihab Ali, MD
P UBLIC HEA LTH
56 H EALT H B Y NUMBER S
Oral Health Concerns and Connections to Mental Health
among Rhode Island High School Students, 2017
Anthony Pellegrino, BS
Travis Vendetti, BS
Tracy L. Jackson, PhD
Samuel Zwetchkenbaum, DDS, MPH
60 Vital Statistics
RH O D E I S L A N D M E D I C A L J O U R N A L
(USPS 464-820), a monthly publication, is Roseann Giorgianni
owned and published by the Rhode Island Deputy State Registrar
Medical Society, 405 Promenade Street, Suite
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rights reserved. ISSN 2327-2228. Published
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do not necessarily reflect the official policy
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ply sponsorship or endorsement by the Rhode
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Medical Society, All rights reserved.
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C ommentary
The why of neurological reflexes
Joseph H. Friedman, MD
joseph_friedman@brown.edu
T h e r e i s a n at u r a l evolved in parallel with editorial policy concerning letters to
tendency to think that the nervous system. I’ve the editor was, I think, a bit more liberal
things exist for a reason, had a greater interest in than it is currently. “Sun sneezes,” more
especially in trying to the less commonly used technically called, “photic-reflexive
understand evolution. reflexes like the palmo- sneezing,” is a reflex sneeze precipitated
The Darwinian concept mental and the corneo- by bright sunlight. It’s fairly common
of survival of the fittest mandibular but also in a and although I had never heard of it
leads people to wonder genetic reflex that runs in before, many who I asked about it were
and theorize about pecu- my own family, photic- well aware. I do not have this reflex,
liarities found in nature reflexive sneezing. although I do sneeze a lot, but two
that seem to have no sur- I had never heard of of my three children have it. I never
vival value. Of course, if “sun sneezes” until a noticed that they had it until I shared
they simply have no negative survival wonderful and entertaining letter was my discovery from the Journal, and two
value the trait may endure forever, printed in the New England Journal told me that they had “sun sneezes”
unchanging until there is some posi- of Medicine many years ago. Their and my observation confirmed this.
tive or negative value that attaches to
the trait. I have read of wonderment
that the appendix exists in modern
man, a presumably vestigial part of
the intestine, without an identifiable
function, that occasionally leads to a
potentially mortal condition. Thus, an
appendix has a negative survival value,
as best we understand, but small. Per-
haps there is some benefit, in an as yet
unknown immune or hormonal role.
As a neurologist I have puzzled for
years over certain neurological reflexes.
Is there some value in their existence?
Of course I puzzle over the “major”
N a t i on a l L i br a ry of M ed i c i ne
reflexes, the ones that are used every
day in clinical neurology, such as the
deep tendon reflex or the Babinski reflex.
Why should a muscle contract uncon-
trollably when tapped? Why should the
large toe go up or down when the sole of
the foot is stroked? These serve no iden- Half-length figure of a child with his hand extended over a small fire; also indicated is the section of
tifiable functional role, but seem to have the brain that operates the mechanism for automatic reaction in response to external stimuli.
R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 8
C ommentary This lack of observation on my part is have a survival value for the rest of the more interesting, and that might, indi- something that is always in the back of village. If this guy isn’t eaten, it’s safe rectly, make me a better clinician. There my mind when seeing patients: “What to go out. are always questions to answer, and am I missing?” “What am I not seeing?” Pain reflexes serve an obvious pur- thinking is what we like to believe our I also wonder just why in the world such pose. When we touch something very brains were designed to do. a reflex should exist. I’m sure someone hot, we withdraw the hand a very short I think of Faraday, one of the great else is wondering what its pathways are. time before the pain hits. We blink when physicists and science teachers of all Occasionally I set myself an exer- something approaches the cornea. We time. He gave six of the most famous cise. How many reasons can I find for don’t think about it. It happens on its lectures in science history, using over a a particular reflex? Usually the answer own. And it’s clearly very protective. hundred observations on a lighted can- is zero. What is the survival value of a Blinking with corneal stimulation, as dle to illustrate how science worked, to sun sneeze? What brain-spinal connec- when a breeze blows into it, or a tiny secondary school students and non-sci- tions are short-circuited to cause the foreign object is lodged on it, causing a entists. Faraday noted that observations palmo-mental reflex, in which a mildly blink and a tear to wash out the object or should trigger two questions: “What is uncomfortable scrape of an object on lubricate the surface is useful. The pupil the cause?” “Why does it occur?” the palm produces a contraction in the contracts with light, which reduces Physics and biology are different. Evo- mentalis muscle (a chin muscle of little stimulation of the retina, a good thing, lution is the result of seemingly random use) on the same side? When I think of but what advantage is there to have the occurrences, restrained by certain rules sun sneezes and evolution, I imagine pupil contract when focusing on a near and refined by raw experience. Perhaps some poor guy walking out from the object? Why should the ipsilateral tes- sun sneezes are linked to other phenom- shade of a forest into the savannah, ticle contract with a brisk stroke down ena that have survival value? Perhaps where it’s bright and sunny, sneezing the inner thigh of a man? It’s hardly pro- future scientists may answer these and getting eaten by a lion. Perhaps sun tective, although maybe it was 20,000 questions. Perhaps not. The answer sneezes are associated with faster reac- years ago. The corneo-mandibular reflex may not matter. I am content to think tion times, or better vision, allowing the involves forced eyelid closure (generally about the questions, an endeavor which sneezer to better detect or respond to a elicited by stimulating the cornea), is always useful. v threat caused by the sneeze? Maybe sun which causes an immediate contraction sneezers taste bad or cause diarrhea and of the contralateral pterygoid (jaw) mus- the sneeze is a warning to a would-be cles which pull the jaw to the side of the Author predator that eating this particular contracting pterygoids, another reflex in Joseph H. Friedman, MD, is Editor-in- homo sapiens would be a bad idea. Or, search of a utilitarian explanation, other chief of the Rhode Island Medical Journal, perhaps sun sneezing might be viewed than providing a question to stump Professor and the Chief of the Division by animals as a boast, “Here I am, come neurology residents. of Movement Disorders, Department of and try to eat me,” and thus an indirect When I ponder questions like this, I Neurology at the Alpert Medical School of warning. Since this peculiar reflex runs tend to think of it akin to an IQ test, Brown University, chief of Butler Hospital’s in my family, although it may reflect which I apparently do rather poorly on. Movement Disorders Program and first my wife’s genes rather than my own, It’s the way I feel when I confront a New recipient of the Stanley Aronson Chair in perhaps this reflex is associated with York Times crossword puzzle. On the Neurodegenerative Disorders. higher intelligence, greater diligence or other hand, it makes clinical practice Disclosures on website R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 9
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The Location of the Aronson Tree
Sutchin R. Patel, MD; Anthony A. Caldamone, MD
In last month’s journal, the article, “The Aronson Tree and
the Roots of Brown’s Medical School” challenged the reader
to find the location of the Aronson Tree. It is located at Brown
University next to the entrance of the Arnold Laboratory on
Waterman Street. The photograph at left can help further iden-
tify the platanus tree that was raised from a seedling that came
from the original Tree of Hippocrates from the Greek island
of Kos and planted by Dean Stanley M. Aronson, MD ,
the medical school’s founding dean.
References
1. Aronson SA. The Tapestry of Medicine, Manisses Communica-
tions Group, Inc ©1999; “A Tree Grows on Waterman Street,”
pp. 31-34.
2. Aronson SA. A Platanus Tree Grows in Providence. RIMJ;
November 2013:13-14.
Authors
Sutchin R. Patel, MD, is a graduate of the Alpert Medical School
and the Brown Urology Residency Program. He was first introduced
to Dr. Aronson through reading his articles “Medical Lexicon,”
published for many years in RIMJ.
Anthony A. Caldamone, MD, is Professor of Surgery (Urology) and
Pediatrics at the Alpert Medical School and is a graduate of the first
Brown Medical School class.
Correspondence
Sutchin R. Patel, MD
sutchin_patel@yahoo.com
R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 11P erspective Is importation of drugs from Canada the answer? Kelly Orr, PharmD; Rita Marcoux, MBA, RPh Increasing medication costs have driven patients to seek substances or biologicals from being imported.3 However, alternative avenues to traditional pharmacy distribution the Controlled Substance Act does allow for a personal use systems for filling their prescriptions. Widespread constitu- exemption for controlled substances but a patient is lim- ent frustration due to the cost of medications in the United ited to 50 dosage units which again must be transported on States has resulted in a wave of state-sponsored legislation person, not shipped into the United States.4 supporting the importation of medication from other coun- The exemption allowing for personal importation of med- tries, in particular Canada. Canada continues to attract the ications from Canada is of limited value for most United attention of United States residents as a cheaper, safe alter- States patients. The demand for access to these less expen- native outlet for their medication. Self-employed groups and sive prescription alternatives has been growing through- municipalities are circumventing laws on importation and out the country. In December 2017, Kaiser Health News offering benefits that include medications from outside the chronicled the growing number of entities, such as school United States. Patients are individually seeking prescription systems, municipalities, and cities, that are quietly offering medications through pharmacy internet sites claiming to their employees the option of using foreign medications at be Canadian in origin. While the cost of medications in for- a reduced employee contribution to healthcare by reducing eign countries may be less expensive, there are many factors deductibles and copays. Employers cited these cost savings as worth considering in regards to foreign acquisitions which enabling the continuation of their employer-sponsored health include, but are not limited to, the safety and efficacy of plans.5 A Kaiser Family Foundation poll in 2016 reported these medications, including purchases from Canada. 8% of respondents had or knew individuals who had used The Food Drug and Cosmetic Act (FDCA) of 1906 and its a non-United States entity for their medications.5 Currently amendments are the safety net for our current drug approval nine states, Colorado, Louisiana, Missouri, New York, Okla- and distribution process. These laws work to strengthen the homa, Utah, Vermont, West Virginia, and Wyoming have manufacturing and distribution systems to ensure that the submitted legislation to operate state-administered whole- supply of United States medication is safe and effective. The sale operations with the intention of importing medications Prescription Drug Marketing Act of 1987 banned the re-im- from Canada and selling to pharmacies.6 Vermont’s bill was portation of medications into the United States, with exemp- passed by the legislature but is currently being examined tions by manufacturers who manufactured the medication or by the Governor’s office as to the implications of impor- for emergency use.1 The Drug Supply Chain Security Act of tation on Medicaid and other federally funded programs.7 2013 was passed in an effort to guarantee the pedigree of med- For those patients with geographical limitations pre- ications distributed through the system. This act requires venting personal importation, individuals across the coun- entities participating in the distribution systems to have the try often look to obtain lower cost prescription drugs from ability to track and trace the pedigree of a medication from Canada through internet sites. Concerns regarding the production through dispensing.2 These amendments were authenticity of “Canadian” drugs coming into the coun- passed to ensure the safety of United States medications and try via online pharmacies have been raised as legislative minimize the counterfeit, adulterated, misbranded, reduced debate ensues in the states. The National Association of potency, or expired medications that might otherwise reach Boards of Pharmacy (NABP) conducted a review of 108 web- United States patients. Protection of United States patients sites between July 1, 2016 and June 30, 2017 that included from harm has not prevented the federal government from “Canada” or “Canadian” as part of their advertised name allowing the importation of medications from Canada. The or URL. The purpose of this review was to validate that Department of Homeland Security Appropriations Act of medications sold by these “Canadian”-identified websites 2007 includes a provision that allows the importation of a originated from non-Canadian pharmacies that distributed Food and Drug Administration (FDA) approved medication medications that had not been approved by Health Canada. from Canada. The provision stipulates that medication may NABP’s review found 80 websites (74%) included language not exceed a 90-day supply and the individual must carry that their medications were not from Canada, they had not the medication on their person. This act prohibits controlled been approved by Health Canada nor were they legally sold R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 12
P erspective within the country itself. The remaining websites omitted sites reviewed are functioning outside of recognized U.S. information regarding origin of the medication used to fill pharmacy practice standards and laws.8 the prescriptions.8 The focus on Canadian medication should be reviewed in Fifty–four of the 108 (50%) online pharmacies included context to the current United States health system. Health in this review provided India or a combination of India and Canada is a universal health plan that does not include med- other countries, such as Hong Kong and Singapore, as the ication coverage. Residents of Canada acquire their medica- country in which the medication was manufactured, or from tion through public and private plans that vary across the where the internet site purchased their medications (which provinces, with some residents having no medication cov- may be different than the country it was manufactured in). erage. The cost of medication in Canada has been reported Various countries were cited as the origin (location) from to be second only to those of the United States. The lack of which the medication was shipped to the pharmacies; how- a unified purchasing system eliminates the ability to nego- ever, 22 (20%) listed unspecified locations abroad while tiate deep discounts for their medications. The pharmaceu- 28 (26%) omitted origin of distribution altogether. These tical cost per capita in Canada is 25% greater than those of unidentified sources and origins of distribution increase the next country with a high expenditure per capita, Ger- the likelihood of counterfeit, adulterated and misbranded many.11 Canada’s Patented Medicine Prices Review Board products reaching United States patients. Also, none of the (PMPRB) does moderate increases on patented medication 108 websites reviewed required a valid prescription and 29 by ensuring that medication drug increases are not exces- (27%) of these internet-based pharmacies were dispensing sive. In addition, the provincial governments implemented controlled substances.8 This is increasingly problematic as policies in 2010 that reduced the cost of generic medications healthcare professionals work to prevent the diversion of but Canadian generic prices still remain high. The PMPRB’s narcotics that is fueling the opioid epidemic in the United report, Generic 360, reported that generic cost in the last States. Each of the pharmacies reviewed in this report appear quarter of 2016 was slightly less than the United States to be neither Canadian, nor operating within the confines of but the seventh highest in the Organization for Economic United States or Canadian law. Co-Operation and Development.12 The cost advantage to These NABP findings support concerns that have been importation from Canada might be less advantageous as the raised regarding the authenticity of Health Canada prod- United States market has shifted and currently has a generic ucts actually making it to the United States. The need for prescription rate approaching 90%.13 affordable medications is often balanced against the safety Federally, importation of foreign medications, otherwise concerns presented by importation of medications. As an commercially available in the United States, is prohibited example, an online pharmacy named Canada Drugs was under the FDA. As individual state governments and their fined $34 million for importing unapproved drugs, includ- legislators consider to legalize importation of Canadian ing counterfeit oncology medications to the United States in drugs, systems must be in place to ensure medications being April 2018. Though claiming to be Canada’s largest internet shipped to their wholesale sites are from verified sources pharmacy, its drugs were sourced from around the globe.9 within Canada. Additionally, the safety and integrity of NABP accredits United States internet pharmacies through medications being sourced from other countries cannot the Verified Internet Pharmacy Practice Sites (VIPPS) pro- be guaranteed by individuals purchasing from the inter- gram. Accreditation ensures that the proprietor is operat- net. Increased monitoring of medications being distributed ing as a safe and legal pharmacy. Full criteria and listing of through internet websites is needed to protect those seeking approved pharmacies can be accessed through the VIPPS cheaper venues for their life-saving medications as internet website (https://nabp.pharmacy/programs/vipps/). Approved pharmacies claiming to ship “Canadian” internet phar- pharmacies have met the criteria which reviews pharmacy macies are likely not dispensing prescription medications practice standards, safety, quality, security, and legal compli- approved by Health Canada or legally sold in Canada. Lastly, ance by the pharmacy. VIPPS accreditation seals will be dis- economics analysis should be performed to ensure the cost played on internet pharmacy sites that have been reviewed of importation ultimately meets the demand for less expen- and have met the NABP criteria. All future VIPPS applicants sive medications. As various states investigate wholesaler must first apply for a .pharmacy domain, also signifying legislation being proposed, the cost of building the infra- the legitimacy of the internet pharmacy within its inter- structure to become a wholesaler, with little to no control net address.10 VIPPS accreditation and .pharmacy recogni- on the negotiated pricing of products in Canada, may be a tion is an important tool for patients looking to utilize safe tenuous way to ensure long-term control of medication cost and legal online pharmacy services. As of June 2017, NABP for United States’ patients. reports that 95% of the approximately 12,000 pharmacy R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 13
P erspective
References Authors
1. The Prescription Drug Marketing Act (PDMA) of 1987, P.L. 100- Kelly Orr, PharmD, Clinical Professor, The University of Rhode
293, 102 Stat. 95 (April 22, 1988) Island College of Pharmacy.
2. Drug Supply Chain Security Act. SEC. 202. PHARMACEUTI- Rita Marcoux, MBA, RPh, Clinical Professor, The University of
CAL DISTRIBUTION SUPPLY CHAIN. Chapter V (21 U.S.C. Rhode Island College of Pharmacy.
351 et seq.) (November 27, 2013)
3. Prescription Drug Importation: A Legal Overview. EveryCRSRe- Correspondence
port.com, Congressional Research Service, [2008 Dec. 1, cited Kelly Orr, PharmD
2018 June 15]. Available from: www.everycrsreport.com/re-
ports/RL32191.html#_Toc392498763. The University of Rhode Island College of Pharmacy
4. DEA Diversion Control Division. Title 21 Code of Federal Regula- Avedisian Hall
tions: PART 1301 — REGISTRATION OF MANUFACTURERS, 7 Greenhouse Road
DISTRIBUTORS, AND DISPENSERS OF CONTROLLED SUB- Kingston, RI 02881
STANCES. [2016 Dec. 16, cited 2018 June 15]. Available from: kellyo@uri.edu
www.deadiversion.usdoj.gov/21cfr/cfr/1301/1301_26.htm.
5. Galewitz, P., and Kaiser Health News. Cities, Counties and
Schools Sidestep FDA Canadian Drug Crackdown, Saving Mil-
lions. Kaiser Health News. [2017 Dec. 8, cited 2018 June 15].
Available at: khn.org/news/cities-counties-and-schools-side-
step-fda-canadian-drug-crackdown-saving-millions/.
6. National Academy for State Health Policy. State Legislative Ac-
tion on Pharmaceutical Prices. [2018 June 7, cited 2018 June 15].
Available at: nashp.org/state-legislative-action-on-pharmaceuti-
cal-prices/.
7. Staff, Associated Press. Vermont Gov. to Study Whether to Sign
Drug Importation Bill. AP News. [2018 May 9, 2018 June 15].
Available from: www.apnews.com/2920f1e7f21b423d8d3caa4c-
ce4f7d7f.
8. National Association of Boards of Pharmacy. Internet Drug Out-
let Identification Program, Progress Report for State and Fed-
eral Legislators: August 2017.[Cited 2017 May 16]. Available
at: https://nabp.pharmacy/wp-content/uploads/2016/08/Inter-
net-Drug-Outlet-Report-August-2017.pdf.
9. Voltz, M., The Associate Press. Canadian pharmacy fined
$34 million for illegal imports. [2018 Apr 13, cited 2018 May
16]. Available at: https://www.apnews.com/7fd1b44d95bc4e-
4187512b3323c00495.
10. National Association of Boards of Pharmacy. Verified Internet
Pharmacy Practice Sites (VIPPS).[cited 2018 June 15]. Available
at: https://nabp.pharmacy/programs/vipps/
11. Morgan, SG, Boothe, K. Universal Prescription Drug Coverage
in Canada: Long-Promised yet Undelivered. Healthcare Manage
Forum. 2016;29(6) 247–254. doi: 10.1177/0840470416658907.
12. Patented Medicine Prices Review Board (www.pmprb-Cepmb.gc.
ca). Generic 360: Generic drugs in Canada, 2016 [2016 Feb., cit-
ed 2018 June 15]. Available at: www.bing.com/cr?IG=665093EF-
D8264490A6A06F2F1665BE03&CID=30B4E270FF4266412603
EE7CFEBF6743&rd=1&h=zIeMuSooD8BHwTYDipqkIaU7h3x-
36zv9DQsc0vVhukM&v=1&r=http://www.pmprb-cepmb.
gc.ca/CMFiles/NPDUIS/NPDUIS_Generics_360_Report_E.pd-
f&p=DevEx.LB.1,5536.1
13. Optum.com. Eden Prairie (MN) 7 Fast Facts About Generic
Drugs. [cited 2018 June 18] Available from: www.optum.com/
resources/library/7-fast-facts-generic-drugs.html
R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 14RECOVERING YOUR MONEY
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The Long Birth and Short Life of The Recovery Navigation Program
Otis U. Warren, MD
If you blinked, you missed it. For a year and a half, Rhode The Long Birth
Island had a comprehensive answer to the plight of the home- And come to the EDs they did. In 2015, at Rhode Island
less alcoholic. The Recovery Navigation Program (RNP) was Hospital alone, 177 high utilizers (patients who made five
born in the Venn diagram overlap of addiction treatment, or more visits for alcohol intoxication) totaled 2,812 visits.
housing, state politics, city policy, fire departments, hospi- Twenty-two of these patients made more than 30 visits each.
tals and Medicaid. In theory, everyone would benefit. Medic- While staggering, these numbers underestimate the phe-
aid would save precious dollars by keeping its members out nomenon because they do not include those who made less
of the hospital, addiction treatment would be more accessi- than five visits, nor do they account for visits where they
ble, EMS would be unburdened from picking these people up were admitted or days as an inpatient in the hospital. Here
on a daily basis, and intoxicated people would now be off the we find the frequent user at his most prolific, with much of
streets and out of the Emergency Department (ED). the health expense attributable to a few individuals.
But it didn’t happen this way. Perhaps we should have National data on this phenomenon mirrors our experience
realized from the outset that this position would be unset- in RI. An estimated 9% of all ED visits are alcohol related.1
tling to those surrounding it. For the RNP to function, the Only 12% of these resulted in admission2, and many of these
Venn diagram itself would have to be radically redrawn. Our visits might have been avoidable. “Avoidable” however, turns
community wasn’t ready for this. out to be a loaded word, and implicit in this conversa-
tion is the question of, “What is a necessary ED visit?”
The Conception While this question could be applied to any chief complaint,
In 1972, Rhode Island enacted a series of laws that decrimi- most visits for alcohol intoxication could be avoided if an
nalized public intoxication. One particular law (23-1.10.10), alternative existed.
detailed that someone “incapacitated by alcohol” be brought Local policy makers have long recognized this. Substantial
to a designated facility for emergency treatment. work leading to the RNP began in 2012 in a State Senate sub-
At the time this facility was the State Detoxification committee. This committee sought solutions and included a
Center, or Ben Rush, as it was commonly known. It was diverse group of people representing public safety, hospitals,
located on the Pastore Complex in Cranston (you know, homeless services, ED doctors, substance abuse experts and
where the DMV is now). It was publically funded through others. A law was passed in 2012 (23-1.10-20) allowing for
the state with federal grants. Access to Ben Rush was easy, a three-year pilot project to take persons “incapacitated by
there was no insurance authorization, medical staff was on alcohol” to an alternative care facility. The Providence Cen-
site and intoxicated people could sober up and then transi- ter won a contract to provide these services, and the Provi-
tion to a detox bed. Most importantly, they accepted people dence Catholic Diocese offered the use of its building above
intoxicated directly from the street, and cared for much of a homeless shelter (Emmanuel House). $250,000 of state
the state’s homeless population, many of them hundreds money was allocated for renovations of Emmanuel House.
of times. It looked like it was ready to go.
In the 1990s Ben Rush was becoming increasingly expen- Then nothing happened. The problem was, as it always
sive and federal grants were drying up, a phenomenon not is, the funding. There was no money stream to provide the
unique to Rhode Island. As the state closed its only public services projected to be around one million dollars annually.
detox facility, it privatized alcohol detox to many indepen- No single entity (hospitals, insurers, Medicaid) would finan-
dent contractors. These facilities quickly developed prac- cially benefit enough by keeping these people out of the ED
tices and policies making it complicated to access their to make it worth their while to fund it. At the same time
services from the street. However, being intoxicated and in everyone lamented the expense in treating this population
public was still defined by law as a medical condition. Now in the ED. The economic problem of the homeless alcoholic
effectively barred from the detox centers and without any was everyone’s and no one’s at the same time.
other options, they wound up in our EDs, like orphans on Meanwhile the Affordable Care Act and Medicaid expan-
the church steps. sion was growing. This population we were seeing in the
R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 16P erspective
EDs was changing from an uninsured to Medicaid predom- the Department of Behavioral Health, Developmental Dis-
inance. Now, the difficult question of “Who is paying for abilities and Hospitals set data points that would deter-
this?” became easier to answer. RI’s state Medicaid office mine the success and safety of the RNP. One of the main
recognized its responsibility and expenses. Through a federal benchmarks was the percentage of patients placed in detox
Medicaid waiver, the RNP was shaken from its slumber and services. However, the very barriers the private detox cen-
given the infusion of funding it needed to keep the doors open. ters imposed after the closure of Ben Rush also affected the
By autumn of 2016, the renovations at Emmanuel House RNP (which ironically was the community’s response to
were finishing up, and the new staff was working out the these barriers).
clinical protocols. The RNP was to open 7 days a week The first barrier was the availability of beds. To determine
between 11a.m. and 11p.m. A registered nurse would be bed availability, caseworkers would call each detox center
on site, as well as an administrator, recovery coaches and individually, as there is no centralized reporting center.
social workers. Providence EMS staff toured the facility and Frequently beds were available but new patients were not
protocols were developed to facilitate EMS transfers. Prov- accepted until business hours the following day.
idence would join San Francisco as the only communities However, the most restrictive barriers were the “medical
in the country to operate sobering centers that accepted clearance” and insurance authorization policies imposed
intoxicated people from EMS. by detox centers. Frequently, clients were told to go from
Here’s how it would work: An intoxicated client would the RNP to the ED for medical clearance. To be clear, these
come in and be assessed by the nurse on duty. If the cli- were clients who would have otherwise been discharged to
ent passed a brief screening exam including vital signs and the shelter had they not wanted detox. Medical clearance
a glucose check, he or she would be allowed to rest until is a nebulous term that means different things to different
reasonably sober. During this time, periodic assessments detox centers. Some wanted labs drawn, some wanted tox-
would be made much like nursing rounds in the hospital. icology screens and some even required psychiatric evalua-
Upon sobriety, the client would be offered detox referrals, tions before admitting patients. It also became apparent that
case management and shelter beds for the night. If a medical “medical clearance” also meant “insurance authorization”.
condition arose, EMS would be called to take the patient to These centers want their patients vetted, able to pay and
the hospital. A physician was on call to handle any ques- only during business hours.
tions about client care. All this was funded en bloc from Furthermore, very quietly, in January of 2018, the state
Medicaid. There was no billing for services. detox contract for uninsured patients expired. Clients with-
out insurance then had no detox program available to them
The Short Life at all. Still, at the RNP, we were held to the metric of placing
The RNP opened on December 1, 2016 and was quickly in these clients in detox.
a fight for its life. One immediate issue was finding staff As the RNP census grew to almost 500 in the first year,
comfortable with this new model. A number of patients it became apparent that many of our clients were undocu-
transported by EMS were being turned away for a variety of mented immigrants (not on Medicaid), walking in or com-
reasons. This reluctance to accept patients soured the rela- ing by an outreach van. At the same time the budget for
tionship between EMS and the RNP’s nursing staff from the the RNP was running at $70,000 per month, all funded
start. Very few people were admitted in those early months. through Medicaid. Medicaid was not getting a return on its
Sometimes days would go by without an admission. investment, and there were no other financial supporters.
Eventually a core staff of nurses (including one who was Hospitals, municipalities, businesses and nonprofits were
also an EMT) served the RNP better. No longer were they supportive in its mission but not in funding.
looking for reasons to send the patient out, but they were On August 8, 2017 Governor Gina Raimondo and Dr.
looking for reasons to keep the patient there. Nicole Alexander-Scott, the director of the Department of
However, the damage with the fire department had been Health, descended on the RNP with an entourage of politi-
done. While the leadership within the fire department pro- cians, advocates and TV crews. Quite ironically, the occa-
moted the RNP, the EMS crews on the street continued to sion was not related to alcohol abuse, but instead was the
take potential clients to the EDs. Ultimately, the EDs were ceremonial signing of three bills addressing the opioid epi-
convenient. The RNP often was not. There was always a demic. The RNP was born into this climate. Public and
chance that the nursing staff would reject the patient, media attention, funding, legislation and resources have
and they would be sent to the ED anyways. In the end a been poured into the opiate epidemic. Alcoholism has taken
few dedicated EMS crews were invested in the mission of a back seat (although it still kills more Americans than opi-
the RNP, and over time most of the slow trickle of EMS ates3), and the RNP fell victim to this. There is only so much
drop-offs came from these few crews. money, media and attention that a community can give to
While the struggle to bring patients in was developing, the substance abuse, and the RNP never developed the robust
struggle to place patients after sobering grew. At the outset, support that it needed in the shadow of opiates.
R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 17P erspective
The Death of RNP References
Death for the RNP came as it usually does for public health 1. Cherpitel CJ, Ye Y. Trends in alcohol- and drug-related emergency
department and primary care visits: data from four U.S. national
projects, in the form of decreased funding. In the spring of
surveys (1995-2010). J Stud Alcohol Drugs. 2012;73(3):454-458.
2018, Medicaid, in a series of cost-cutting measures, changed 2. Pletcher MJ, Maselli J, Gonzales R. Uncomplicated alcohol in-
the way it funded the RNP. Instead of bloc funds, it would toxication in the emergency department: an analysis of the Na-
create a billing structure so that the RNP would bill Medic- tional Hospital Ambulatory Medical Care Survey. Am J Med.
2004;117(11):863-867. doi:10.1016/j.amjmed.2004.07.042.
aid clients for each visit. The problem was, undocumented
3. Centers for Disease Control and Prevention. Alcohol Related
immigrants made up 50 percent of the visits. Only able to Disease Impact (ARDI) application 2013. Available at www.cdc.
bill for half the services, the RNP was doomed. It closed qui- gov/ARDI
etly on July 1st of this year. And with that our State’s inno-
Author
vative response to this national public health epidemic was
Otis U. Warren, MD, Associate Professor of Emergency Medicine,
quietly put to rest.
Warren Alpert Medical School, Brown University; former medical
At the end it was open for only 18 months; 1,200 visits
advisor to The Recovery Navigation Program.
were made, about 30 percent of them by EMS diversion.
There were no adverse medical outcomes. This was a suc-
cess for all the clients served, just not for Medicaid.
When the state decriminalized public intoxication in the
1970s, it created a medical framework to deal with this prob-
lem. Now we are stuck in the medical model without the
public infrastructure to address it as intended. At the RNP,
we tried to demedicalize public intoxication. Instead we
found out how difficult this was and how far reaching its
ramifications are. If we are going to change this cycle for our
patients, we are first going to have to change our community.
R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 18One Call Does It All!
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OBSTETRIC S / GY NECO LO GY The Obstetrician/Gynecologist (OB/GYN): Revisiting the Past, Exploring the Present and Preparing for the Future Roxanne Vrees, MD Guest Editor The primary purpose of the American Board of Obstetrics Sebastian Z. Ramos , E. Christine Brousseau , and and Gynecology (ABOG) is to, “advance women’s health Jennifer G. Clarke , highlights the important work that through the study and practice of Obstetrics and Gynecol- has been done at the local and national levels to improve ogy.” Similarly, the American College of Obstetricians and access to necessary healthcare for incarcerated women, with Gynecologists (ACOG), a private non-profit organization particular emphasis on the remarkable accomplishments of with approximately 60,000 members nationally, is a strong Dr. Clarke, Medical Programs Director at the Rhode Island advocate of high quality, evidence-based care, and fosters Department of Corrections, and her colleagues. increased awareness among patients and providers of the The Perspective article, “Current Threats to Contracep- ever changing issues facing women’s healthcare. Despite tive Access,” by Drs. Leanne Free , Kathleen Cohen the guidance and support of these parent organizations, and Rebecca H. Allen , reflects on the very real and cur- there have been significant changes to the field of women’s rent threats to a woman’s fundamental reproductive health healthcare that has prompted close scrutiny of our specialty rights. While we recognize that the political landscape has alongside residency training programs, to ensure that our great influence on access to contraception, we are hope- current generation is adequately prepared for future practice. ful that this discussion will bring to light the importance A true landmark in the evolution of our specialty was of all providers, not just Ob/Gyns, advocating for patients’ the introduction of dedicated women’s hospitals. The first unrestricted access to family planning resources. model, Lying-in hospitals, was established in Strasbourg, In response to the concerning trend of increased maternal France in 1728. The development of similar hospitals fol- mortality among high-resource countries such as the United lowed in Great Britain and the United States with the pri- States, Drs. Erika Werner and Bridget Spelke examine mary goal of providing care to underserved populations. the concept of the “Fourth Trimester of Pregnancy.” Their Women & Infants Hospital, the primary teaching hospital discussion implores all healthcare providers in Rhode Island, in obstetrics and gynecology and newborn pediatrics of the regardless of their chosen specialty, to seize the opportunity Alpert Medical School of Brown University, was founded for maternal risk reduction and health promotion during in 1884 as the Providence Lying-In Hospital. At that time pregnancy and beyond. the hospital was used exclusively for maternity care and Similarly, in response to the current data on maternal childbirth. While the hospital has undergone four location deaths in our state, the featured article, “On the Future of changes and rebranding in 1996 to become a part of the Care Maternal Mortality Review in Rhode Island,” by Drs. Brid- New England Health System, its core values of providing get Spelke , Sebastian Ramos , Hope Yu , Michael high quality, unbiased women’s health care have never Cohen and Tanya L. Booker , commends the Rhode wavered. What’s more, the institution has expanded its Island Medical Society for its prior support of mortality scope to include highly specialized services in breast care, review committees at the legislative level, while imploring infertility treatment, gynecologic cancer, pelvic floor disor- our small state to take a big lead on both near misses and ders and prenatal diagnosis. Impressively, the Department maternal death reviews. of Obstetrics and Gynecology was recently ranked 11th in The field of obstetrics and gynecology is rich, with a vari- U.S. News & World Reports’ 2019 Best Medical Schools ety of subspecialties that have ultimately shifted the overall specialty rankings. scope and practice of modern general Ob/Gyns. In the 1990s, This month’s issue of the Rhode Island Medical Jour- greater than 90 percent of trainees chose a career as a general nal features timely and important perspectives on critical Ob/Gyn, as compared to 70 percent currently. As more and areas in the field of obstetrics and gynecology. “Prison: Pipe- more graduates pursue fellowship training and are drawn to line to Preventative Health,” by Drs. Luwam Ghidei , larger metropolitan areas, this creates shortages of providers R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 21
OBSTETRIC S / GY NECO LO GY and disparities in access to care in other locations. Rhode Guest Editor Island has certainly been impacted by this. Additionally, Roxanne Vrees, MD, is Medical Director of Emergency Obstetrics despite the changing landscape of our specialty, residency and Gynecology at Women & Infants Hospital and Assistant Pro- training programs have remained relatively unchanged. The fessor of Obstetrics And Gynecology at The Warren Alpert Medical article, “A Melting Pot of Medical Education,” by Drs. School of Brown University. Merima Ruhotina and Dayna Burrell , explores the challenges and solutions that exist for trainees and educators in a unique women’s Emergency Department. It highlights the importance of thoughtful integration of the education of our medical students and residents into our often fast-paced clinical environments. As leaders in the field of women’s healthcare, we are poised at institutions like Women & Infants to transform the perceptions and expectations of the 21st-century special- ist in general obstetrics and gynecology. Tackling important topics like those featured in this issue will enable our spe- cialty and training programs to evolve and continue to meet the complex needs of our patients. R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 22
OBSTETRIC S / GY NECO LO GY Prison: Pipeline to Women’s Preventative Health Luwam Ghidei, MD; Sebastian Z. Ramos, MD; E. Christine Brousseau, MD, MPH; Jennifer G. Clarke, MD, MPH Women detained in prisons, jails and juvenile centers rep- whether or not they desire contraception or if pregnant, resent an underserved population. In her highly acclaimed continuation of a pregnancy, abortion, or adoption services. book Jailcare, Dr. Carolyn Sufrin explores how and why The NCCHC recommends that correctional institutions prison can paradoxically serve as a place where women find recognize community standards for women’s health ser- healthcare.1 As the rate of incarceration for women contin- vices.4 Accordingly, all women entering correctional facil- ues to increase, it is prudent to assess the current state of ities should be offered screening for sexually transmitted healthcare in correctional facilities and leverage this institu- infections (STIs). In a 2008 study of women entering jail in tion to link more women to care. Rhode Island, 33% tested positive for an STI at admission and In December of 2017, women accounted for approximately 26% of all women had trichomoniasis.5 Detecting and treat- 7% of the national detained population.2 While the rate at ing women in correctional settings has an impact on com- which women are incarcerated varies greatly from state to munity prevalence of these infections. For example, in 2011, state, the number of women in prison has been increasing correctional facilities accounted for up to 6% of reported at a rate 50% greater than men since 1980. Notably, Rhode syphilis cases in the United States.4 One correctional facility Island is the state with the lowest incarceration rate with was able to demonstrate that prompt treatment of all syphilis 12 out of every 100,000 women incarcerated in 2014.3 As cases in a jail can lead to a substantial decrease in the preva- the smallest state with the lowest incarceration rate, Rhode lence in the local community.6 RIDOC is currently working Island is uniquely positioned to make large gains with with the Rhode Island Department of Health (RIDOH) to optimization of healthcare for incarcerated women. offer urine-based STI testing to every woman who enters the Incarcerated women disproportionately suffer from alcohol facility, exemplifying the partnership between the RIDOC and drug abuse, sexually transmitted infections (STI), sex- and the RIDOH in providing public health services to this ual and physical abuse, and mental illness, with rates of population. In addition to STI screening, all women should these conditions higher than those of incarcerated men.4 be offered pregnancy testing within 48 hours of entering a This paper will highlight the major disparities in women’s correctional facility. According to the American College of health care in the prison population nationally, the current Obstetricians and Gynecologists (ACOG), at any given time, interventions within the Rhode Island Department of Cor- approximately 6% to 10% of incarcerated women are preg- rections (RIDOC), and the future steps needed to improve nant and many first learn they are pregnant when they enter healthcare in incarcerated populations. a correctional facility.7 In 2004, a federal survey found that Ideally, healthcare in prison should serve as a safety net 3% of women in federal prisons and 4% of those in state alongside a pipeline for preventative health to help women prisons were pregnant upon arrival.8 In a cohort of Rhode on the margins of society climb onto integrated, quality Island inmates, only 28% of sexually active women used healthcare once they leave the system. The National Com- birth control consistently and 83.6% had unplanned preg- mission on Correctional Health Care (NCCHC) guidelines nancies.9 This speaks to the need of improving family plan- recommend several standards of OB/GYN care for deten- ning services both inside correctional facilities as well as in tion centers including: systematic screening for gyneco- the community. This population tends to have complicated logic problems and pregnancies; initial health assessments pregnancies and is inconsistently provided counseling on including pap smears and pelvic exams; caring for the preg- options or access to termination services nationwide.10 nant woman throughout her prenatal course; and assessing Women in prisons and jails disproportionately suffer pregnant inmates for opioid use disorders.4 These encounters from mental health disorders with up to 75% of incarcer- should strive to provide care and counseling that does not ated women having a mental health disorder.11 Additionally, infringe on the reproductive rights of these women who are more than 40% of female prisoners are found to abuse drugs already marginalized when considering the poverty, addic- at the time of their entry to correctional facilities. When tion, violence, and racial oppression that characterize their incarcerated women with opioid use disorders are pregnant, lives.1 Importantly, this counseling should foster principles they should be offered medication for addiction treatment of reproductive justice allowing pregnant women to choose (MAT) in correctional facilities. Although pregnant women R I M J Arch i v e s | O C TOBE R ISSUE W e b p a g e | R I M S OCTOBER 2018 Rhode isl and medical journal 23
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