March 2013 Newsletter - American College of Medical Toxicology

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March 2013 Newsletter - American College of Medical Toxicology

The official newsletterof the American Collegeof Medical ToxicologyA Bimonthly Newsletter ! March 2013TABLE OF CONTENTSPresident’s Perspective! ..................................................................................................................................... 1Medical Toxicology Fellowships to join the NRMP (National Resident Matching Program)! ....................... 3Toxicology Investigators Consortium (ToxIC) Update! .................................................................................... 4ACMT Addiction Medicine Section! ................................................................................................................... 5Billing Addiction Medicine Services as a Medical Toxicology Consultant! ................................................... 6ACMT Forum Features! ....................................................................................................................................... 7Oh The Places You Could Go...! ......................................................................................................................... 8MTFITA Minute! .................................................................................................................................................... 9JMT Update! ....................................................................................................................................................... 10Affiliate Membership – An Introduction! .......................................................................................................... 11Welcome 2013 Fellows of the College! ............................................................................................................ 12Member News! ................................................................................................................................................... 12Calendar of Events! ........................................................................................................................................... 13President’s PerspectiveSuzanne White, MD, FACMTPresidentOn behalf of theBoard of Directorsand the AwardsCommittee, I cansay that it was bothenlightening andinspiring to reviewthe nominations putforth this year forthe College’sprestigious awards. The number ofprominent physicians who have madesignificant contributions to the field ofmedical toxicology is growing and thedeliberations were challenging. Iconsider it an honor to be able toannounce the 2013 awardees andhumbling to outline some of theirremarkable accomplishments here.ACMT’s most esteemed award is TheMatthew J. Ellenhorn Award whichhonors an individual who has madeextraordinary contributions to the fieldof medical toxicology. Many of you willremember Dr. Ellenhorn as a beloved,distinguished educator and clinician. Assuch, the Awards Committee and theBoard are extremely pleased to announcethe 2013 Matthew J. Ellenhorn Awardeeis Jeffrey Brent, MD, PhD, FACMT.As a unique testament to Dr. Brent’scareer impact, numerous colleagues,including many prior fellows-intraining,nominated him “not only forhis overwhelming breadth ofknowledge, but more importantly for hisability to impart this knowledge uponstudents of our field.”Dr. Brent is known for a careercompletely dedicated to advancingmedical toxicology science and practice.He has participated in a wide range ofclinical trials and has publishedprolifically in numerous journals, fromthe College’s own, Journal of MedicalToxicology to the New England Journal ofMedicine. Impressively, over 50 of his 130publications are original studies. Dr.Brent has researched and writtenextensively on acetaminophen, cocaine,animal envenomations, and thetreatment of toxic alcohol poisoning. Hisresearch and successful collaborationshave culminated in the publication of hisclassic text, Critical Care Toxicology,Diagnosis and Management of the CriticallyPoisoned Patient.Dr. Brent has served as a mentor togenerations of toxicologists. Uponcompleting his fellowship in medicaltoxicology at the Rocky Mountain Poison& Drug Center in 1989, heenthusiastically taught fellows,residents, and students at the Universityof Colorado, ultimately becoming theMedical Toxicology Fellowship ProgramDirector. Even today, Dr. Brent continuesto mentor fellows at the Rocky MountainPoison and Drug Center as Professor ofPharmacology and Toxicology. Of note,he hosts the ever-popular, annual ACMT American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 1


Fellow Roundtable Discussion at ourannual meeting, advocating for fellowinvolvement in national organizations,providing valuable insight into the field,and giving advice on establishing asuccessful career as a medicaltoxicologist. He has provided extensiveservice and leadership to the Collegeincluding serving on the ACMT Boardof Directors; chairing the Task Force onEthics, the Practice Committee, and theEducation Taskforce; and directingcooperative agreements with the CDC.In 2008, it was his vision and sedulouseffort that established the ACMTToxicology Investigators Consortium(ToxIC) which he continues to direct.For his many contributions, he has beenrecognized by numerous ACMT partnerorganizations, such as the EuropeanAssociation of Poison Control Centresand Toxicologists and the AmericanAcademy of Clinical Toxicology. Withover 30 years of experience in the field,Dr. Brent maintains a busy clinicalpractice and is considered one of themost credible experts in medicaltoxicology. It is with great pride that weplace Dr. Brent’s name, most deservedlyand long overdue, on the list ofMatthew J. Ellenhorn Award recipients.Each year, ACMT also honors a memberwho has made significant contributionsspecifically to educational pursuits inmedical toxicology. On behalf of theBoard, I am very pleased to announcethat the 2013 ACMT Award forOutstanding Contribution to MedicalToxicology Education is awarded toAndrew H. Dawson, MBBS. Dr.Dawson has a 20-year track record ofbuilding locally relevant, accessible andsustainable educational programs. In1989, he developed HyperTox, a series ofclinical toxicology monographs linkedto electronic training activities. As theplatform for the famous NewcastleClinical Toxicology Fellowship,Hypertox was fundamental todeveloping the careers of graduates likeDrs. Nicholas Buckley and GeoffreyIsbister. A web version of HyperTox wasincluded in the Widernet project(www.widernet.org), an initiative todistribute offline versions of webresources to countries lackingbandwidth. In 2004, Dr. Dawsonbecame the convener of multipleresources that now support a distancelearning Masters in Clinical Toxicologydiploma course with uptake by themajority of medical toxicologists inAustralia. In a recent, capacity buildinginitiative with Sri Lankan collaborators,Dr. Dawson created an open-sourcetoxicology curriculum (wwwwikitox.org) supported by the WHO andthe South Asian Clinical ToxicologyResearch Collaboration (SACTRAC).Wikitox currently receives 300,000 pagehits per year and supports educationaldelivery to trainees in Sri Lanka,Australia, India and Bangladesh.Educational research in medicaltoxicology is very rare. As such, it isnoteworthy that Dr. Dawson wasexternally funded to pilot a study ofbrief educational interventions in 42rural Sri Lankan hospitals and tosubsequently examine the impact ofexpanding that intervention to 104 ruralhospitals.Dr. Dawson is a well-known, frequentcontributor to the medical toxicologyliterature and presenter at nationalcongresses. However, it is his passion forevidence-based, educationalinterventions that promote the practiceof medical and clinical toxicology inresource-restricted settings that is uniqueamong toxicologists and makes him sodeserving of this honor.The ACMT Board is particularly honoredthis year to bestow the 2013 ACMTOutstanding Service to the CollegeAward upon Mark Kirk, MD, FACMT.During Dr. Kirk’s medical toxicologycareer, he has demonstrated a passion fordeveloping communication andresponse mechanisms that assistemergency responders and emergencyreceivers caring for victims of HazMatsituations. His findings in this arena arewell-known and published in the peerreviewedmedical literature. Also ofnote, Dr. Kirk assisted in thedevelopment of ACMT’s pioneeringChemical Agents of Opportunity Course,creating the Module on PsychologicalAspects of Mass Exposure. Over the pastdecade, Dr. Kirk has been the coursedirector and lecturer at most of thesecourses, which have been very wellreceivedby thousands of participants.Dr. Kirk was highly sought after for anew position with the U.S. Departmentof Homeland Security (DHS) as itsMedical Director of Health Affairs.According to Dr. Charles McKay, one ofhis closest colleagues, “in this newlycreated position, Mark was able to bringtogether his proven expertise andunderstanding of the human response tothe threat of exposure (or actualexposure) with his demonstrated passionand understanding of the importance ofinvolving medical toxicologists in policydiscussions at the federal governmentlevel. In this role, Mark highlighted thecritical role of the medical toxicologist inour nation’s response to the threat ofchemical terrorism.”Dr. Kirk has tirelessly promoted medicaltoxicology as deserving a “seat at theplanning table” by directing workshops,assisting with policy development, andcultivating relationships with publichealth and security personnel. As justtwo examples, discussions around masshuman decontamination and theunification of toxidrome terminologybrought medical toxicologists togetherwith policy makers to improve responsecoordination. Very recently, Dr. Kirk’sleadership paved the way to a successfulpartnership between ACMT and DHSthat engages regional medical toxicologyexperts as high-level resources. This pilotprogram will help to address concernsregarding possible chemical releases,provide government agencies withsecurity-cleared surge capacity, assistmedical toxicologists at other agencies,and establish critical communicationlinks between law enforcement and themedical community. For his tremendousadvocacy on behalf of medicaltoxicologists regarding our role inemergency response, and for creatingnumerous growth opportunities forACMT, we thank Dr. Kirk and recognizehis outstanding service.Lastly, during this landmark year whenoriginal research presentations will bedelivered for the first time at our ACMTAnnual Scientific Meeting, it is especiallymeaningful that the Board is recognizingYaron Finkelstein, MD as the recipient American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 2


of the 2013 ACMT OutstandingContribution to Medical ToxicologyResearch Award. Unique amongaccomplished researchers in medicaltoxicology, Dr. Finkelstein hasdemonstrated exemplary use of theACMT Toxicology InvestigatorsConsortium (ToxIC) Registry as aresearch tool. Shortly after thedevelopment of the ACMT ToxICRegistry in 2008 by Dr. Brent and others,Dr. Finkelstein completed threeimportant studies using the database.His first study on the toxicosurveillanceof infant and toddler poisonings waspresented at the prestigious Society forPediatric Research. The findings quicklyspread across pediatric and emergencymedicine Internet sites and ultimatelyresulted in an ACMT press release onthe importance on the topic. Since then,Dr. Finkelstein has completed twoadditional ToxIC-based studies on druginducedseizures in children andpoisonings in pregnancy. Dr. Finkelsteinhas demonstrated solid leadership to theToxIC program, serving on its SteeringCommittee and as a co-author of the2011 ToxIC Annual Report. At the recentNorth American Congress of ClinicalToxicology, Dr. Finkelstein delivered anexcellent presentation demonstrating theuse of the ToxIC Registry as a researchtool.Dr. Finkelstein is Associate Professor ofPediatrics and Pharmacology/Toxicology at the University of Torontoand serves as a consultant to the OntarioPoison Information Center. He hasauthored 69 original papers and has over50 other publications. He is the recipientof a number of research grants andmultiple professional honors andawards. He serves as a reviewer formany scientific and medical journals.Most importantly, Dr. Finkelstein is arole model for aspiring academicmedical toxicologists both through hisdevelopment of a highly productiveresearch program and through his adeptuse of the ToxIC Registry to promotenew knowledge in the field.Please join me and the ACMT Board ofDirectors in Puerto Rico next month atthe President’s Reception to personallycongratulate and thank these highlydistinguished individuals.Return to Table of Contents2013 ACMT Award RecipientsJeffrey Brent, MD, PhD, FACMTAndrew H. Dawson, MBBSMark Kirk, MD, FACMTYaron Finkelstein, MD2013 Matthew J. Ellenhorn Award2013 ACMT Outstanding Contributionto Medical Toxicology Education2013 ACMT Outstanding Service tothe College Award2013 ACMT Outstanding Contributionto Medical Toxicology Research AwardMedical Toxicology Fellowships to join the NRMP (National Resident MatchingProgram)Steven Aks, DO, FACMTAfter many years of discussion and debate, the Fellowship Directors via the ACMT Fellowship Directors’ Committee voted to join theNational Resident Matching Program. This move will professionalize the process of interviewing and selecting future MedicalToxicologists.The following lists the timeline for the match in 2013:• August 7, 2013! ! Match opens• September 25, 2013! Rank order list entry opens• October 23, 2013! ! Quota change deadline• November 6, 2013! Rank order list certification deadline• November 20, 2013! Match DayPlease circulate this information to your faculty, fellows, prospective applicants, and interested colleagues. Feel free to contact me withquestions at saks@cookcountyhhs.org.Return to Table of Contents American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 3


Toxicology Investigators Consortium (ToxIC) UpdateToxIC Is BoomingJeffrey Brent, MD, FACMT and Paul Wax, MD, FACMTThere is so much going on in the ACMT ToxIC program that it would take this entire newsletter to keep you up to date. In the interest ofyour time, and our space available, we will just update you on a few key activities and events about which you may be particularlyinterested.Our snakebite sub-Registry is all set for being piloted. In the next approximately one month or so it will be active and ready for ToxICparticipants to use to enter their cases. When adding a snakebite case to the Registry you will have the opportunity to enter the sub-Registry and to fill in additional information, including follow up, of these patients. This project, funded by a grant, and under theleadership of Michelle Ruha, MD, FACMT, will be the largest and most comprehensive Registry of information relating to NorthAmerican snake bites in existence. ToxIC members who enter these cases will be paid $75 for each completed case, will be considered tobe a member of the snakebite study group, and acknowledged as such in any publications deriving from this effort.A new project on prescription opioid abuse is soon to go through pilot testing and then will be available as a sub-Registry for any ToxICmember who wishes to participate. Shawn Varney, MD, and Colleen Rivers, MD are leading this project. Prescription drug abuse is anepidemic-magnitude problem in US society and as medical toxicologists, we have the advantage of seeing and studying specifically thosecases that develop medical complications as a result of their drug use. The plan now is to develop sufficient preliminary data to allow usto secure funding for a long-term in-depth study.The lipid therapy and the caustic ingestion sub-Registries, spearheaded by Michael Levine, MD and Zhanna Livshits MD, respectivelycontinue to be available for data entry. We encourage you to enter your data on patients who are appropriate for these studies.For all the studies, ongoing studies authorship and study group criteria can be found on the ToxIC website under the Research link onthe left of the page.There are several new studies in the formative stage – more on these at a later time.The ToxIC Severity score project is continuing under the leadership of Evan Schwarz, MD. Actual data collection has not yet started.More to come on this project at a later time as well.The NACCT abstract deadline of April 17 th is coming up quickly. There are many abstracts that could be put together using alreadycollected ToxIC data. We encourage all ToxIC participants to utilize the strength and diversity of the ToxIC database to generate abstractson topics about which they have an interest. If you want to generate an abstract based on ToxIC data please let us know atToxIC@acmt.net. We are glad to advise and assist, if that helps. Please remember that any ToxIC research must be approved by theResearch Committee. We would be glad to help you facilitate that process.We have a couple of important announcements.Christopher Hoyte, MD, has joined the ToxIC leadership team and will serve as Site Coordinator. In that important role, Chris will bekeeping in touch with all participating sites and serving as a resource to them for any problems, concerns, new ideas etc. Chris can bereached at ToxIC@acmt.net.We hope to see many of you at the Annual Scientific Meeting in San Juan next week and will be hosting a meeting for all ToxIC members,or anyone else, who wishes to attend. We have many important agenda items to be covered at that meeting and are hoping to seduce asmany ToxIC members off the beach and into the meeting as possible. If there are any agenda items you want to include please let usknow at ToxIC@acmt.net. We look forward to seeing you there…..travel safely!Return to Table of ContentsHave you paid your dues?The deadline for 2013 membership renewal was December 31, 2012.In order to renew, please go to www.acmt.net and simply login to the 'Members Only' section of the site, select 'RenewNow' and follow the prompts. American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 4


ACMT Addiction Medicine SectionA Moment of Clarity –And OpportunityJoAn Laes, MDWell before recent articles such as “A Pain-Drug Champion HasSecond Thoughts” featured in the Wall Street Journal (December17, 2012) or “Rising Painkiller Addiction Shows Damage fromDrug maker’s Role in Shaping Medical Opinion” fueled furtherpublic dialogue regarding prescription drugs and addiction, thetoxicology community began to understand that there was adramatic tide of repercussion facing the medical community ingeneral and society in whole from the excessive prescribing ofopioids. This became more painfully clear as reports confirmedthat drug overdose deaths had surpassed motor vehicleaccidents as the number one cause of accidental death from ages19-55 and that overdose deaths from prescription drugssurpassed deaths from the illicit drugs heroin and cocaine [1, 2].Whether in the Emergency Department, on a consult service, orthrough a poison center, most toxicologists directly treat opioidoverdose victims. Alcohol and other drug abuse are alsocommon in our patients. Various medical comorbidities areinherent in this population, including addiction. As addictionaccompanies our patients, the identification, prevention andtreatment of addiction and the corresponding medical conditionsshould accompany our skill sets as Toxicologists.In Filling a Void in Medical Education Regarding Opioids featured inthe recent Journal of Medical Toxicology special issue detailingvarious aspects of prescription opioid abuse and addiction,Patrick Lank, MD a fellow at the Toxikon Consortium in Chicagoproposed that Medical Toxicology could "at every level ofmedical education make the greatest influence on the opioidepidemic in the USA." To maximize the toxicologist's ability todisseminate education regarding the toxicities of addictivesubstances and pharmaceuticals, further training in addictionmedicine should be incorporated into our own careers.Integration of addiction medicine principles into the medicaltoxicology curriculum can range from traditional didactics toclinical experiences, and would greatly benefit the field oftoxicology by expanding knowledge and ability to care forpatients.Addiction medicine is a specialized field that deals with thetreatment of addiction, with cross-over into various other areasof medicine such as psychiatry, primary care/internal medicine,toxicology, and emergency medicine. Treatment of addictionrequires an understanding of the pharmacological andtoxicological properties of the abused substances and thepharmaceuticals used for treatment. Expertise in medicaltoxicology necessitates a detailed understanding of pharmacokineticand pharmaco-dynamic principles of pharmaceuticalsand drugs of abuse. Toxicologists are well-equipped tounderstand potential drug interactions and side effects ofpharmacological treatments for addiction, but are lacking inopportunities to impart this expertise in clinical settings andoften do not receive training in the psychosocial and legalaspects of addiction medicine. The American Society ofAddiction Medicine has a wealth of information and trainingmaterials in both live and e-learning formats. The society puts onan excellent board review course that teaches the basic principlesof addiction medicine; samples topics include neurobiology ofaddiction, challenges in pain management, opioid pharmacology,and clinical uses of drug testing. Other e-live learning contentincludes coding and billing for addiction medicine and trainingon brief interventions to screen for unhealthy alcohol use andfollow up with effective brief counseling.The knowledge gained through working with addictionmedicine specialists broadens the quality and range of servicesprovided by toxicology consultations. Buprenorphinemaintenance is an increasingly common office based treatmentfor opioid addiction. When a patient maintained onbuprenorphine is hospitalized, it can be difficult for inpatientproviders who are not familiar with the pharmacology andmechanisms of buprenorphine to manage potential druginteractions, treatment of pain, and the legal issues surroundingpharmaceutical treatments for addiction in thehospital. Treatment of acute pain in a patient maintained onbuprenorphine depends on several patient factors -- expectedtime course of acute pain, last dose of buprenorphine, and mayinvolve increased dosages of opioids that a less experiencedphysician would be uncomfortable with. The toxicologist canfunction as a resource regarding medical management of thepatients as many hospitals do not have addiction medicinespecialists that are available for consultation. Shadowing anaddiction medicine physician in a buprenorphine clinic inaddition to reviewing online training materials for certification toprescribe buprenorphine would be an excellent starting point forthe toxicologist to gain experience in the use of buprenorphine.Methadone has been used for treatment of opioid dependencesince the 1960's, but the pharmacology and toxicology of thismedication is often misunderstood. Toxicologists are often calledupon to assist in the emergent management of patients who havepotentially overdosed on methadone. The length of timerequired for observation of potential respiratory depression dueto narcotic overdose or safety in resumption of methadone afteroverdose are common clinical questions posed to theconsultation service. The risk of inadvertent overdose can bemitigated with correct timing of administration and doseincreases with consideration for the various factors that affectmetabolism of methadone (anticonvulsant use, pregnancy, orCYP genotypes). Review of methadone induction doses andmethadone maintenance regimens can be achieved throughattendance at administrative meetings of opiate treatmentprograms or review of literature on methadone maintenance fortreatment of opioid dependence.Continued on next page American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 5


Principles of neuro-transmission and pharmacology are the basisfor development of pharmacological treatments for addiction.The toxicologist is in a prime position to propose novel therapiesor guide investigative studies on existing pharmaceuticals. Giventhe difficulties in conducting randomized controlled studies onpoisonings and overdose, research on therapeutics for addictionmay be a venue to expand academic studies. Research topics canrange from efficacy of pharmacological treatments for cocaineaddiction to evaluation of the safety profile of naltrexone whenprescribed for alcohol dependence.Emerging patterns of recreational drug use are often identified inthe emergency department. Patients intoxicated with bath saltspresented with difficult to control agitation and were initiallyrecognized by paramedics and emergency departmentphysicians due to the nature of their clinical signs andsymptoms. Often the Emergency Department is the only medicalsetting that these patients encounter- many do not haveadditional medical problems that require regular care through aprimary care physician or psychiatrist. Toxicologists are in aunique position to offer screening for drug abuse or dependenceto these patients and counsel them on the physical and mentalhealth effects of their drug use. Studies in various health-caresettings on brief screening and counseling demonstrate costeffectiveness and observed decreased drug and alcohol use(Madras et al., 2009). Screening and counseling for tobacco andalcohol abuse and dependence is a natural extension of servicesalready provided by a toxicology consultation; expanding thescope of service would reinforce the economic value and qualityof patient care provided by the toxicology consultation service.There are a number of validated screening tools that can be used(for example -- CAGE, AUDIT, or DAST) and counseling skillscan be enhanced through online training or lectures provided bychemical dependency specialists.Addiction medicine is a small but growing specialty with manysimilarities to the field of toxicology. Toxicology would be servedwell to incorporate addiction medicine education into coretraining. Proficiency in addiction medicine principles broadensthe skills that toxicologists are able to utilize for managingpoisoned patients and offers further opportunities forpractice. The curriculum provided by toxicology fellowshipprograms could easily be expanded to incorporate academic andpractical experience in addiction medicine. Prescription drugmisuse remains a top public health concern and this is theopportune time for toxicologists to dedicate their involvement inthis critical issue.ACMT has identified Addiction Medicine as one of the six practicepathways to develop and highlight for career and practice opportunities.For more information about opportunities to expand your practice inaddiction treatment or to become active in the addiction medicinesection please contact section chair Timothy Wiegand, MD attimothy_wiegand@urmc.rochester.edu1.! Manchikanti, L., et al., Opioid epidemic in the United States. PainPhysician, 2012. 15(3 Suppl): p. ES9-38.2.! CDC grand rounds: prescription drug overdoses - a U.S. epidemic.MMWR Morb Mortal Wkly Rep, 2012. 61(1): p. 10-3.Return to Table of ContentsBilling Addiction Medicine Services as a Medical Toxicology ConsultantExamples of Suboxone Induction and Smoking CessationTim Wiegand, MD, FACMTThere are an increasing number of patients presenting to the hospital maintained on Suboxone and many of them will have need or expertise instarting/stopping/maintaining Suboxone along with other services a Toxicologist is able to provide. The following case illustrates reimbursementopportunities for adding addiction management such as Suboxone induction and tobacco cessation to your inpatient Medical Toxicology ConsultService.A 54 year-old gentleman had been treated for opioid dependence by one of the local addiction psychiatrists and had been doing well forover 2 years. He’d completed an intensive outpatient treatment program for prescription opioid dependence and been maintained on 16mg (8/2 mg SL BID) of SL buprenorphine daily with monthly visits. The patient had a long history of tobacco use although for severalyears he had been trying to quit. He had severe COPD and frequent bouts of bronchitis with COPD exacerbations. I had become involvedwith his care after he had been admitted to the hospital this winter with respiratory distress and severe COPD exacerbation. He’dpresented to the Emergency Department with respiratory distress from a COPD exacerbation and despite receiving oxygen, nebulizertreatments and antibiotics, deteriorated and required intubation. His sedation requirements were quite high. The ICU team hadn’tinitially understood that the fentanyl effect would be quite limited due to the patient’s regular and prescribed use of buprenorphine. Infact, the Suboxone hadn’t been ordered for continuation during the admission history and physical. The admitting resident hadn’tunderstood the purpose, not to mention the implications that the maintenance dose of 16 mg buprenorphine would have on the patient’sadmission. Over the first week, the patient’s respiratory function improved and he was extubated. During intubation he had beenmaintained on a combination of fentanyl and midazolam and he had a very difficult time with any weaning of the fentanyl –which hadbeen infused at 200 mcg/hour with additional boluses throughout the day. The doses of fentanyl were dropped over the next couple ofdays post-intubation but the patient became very diaphoretic, his heart rate increased and he had severe anxiety with the dosagedecrements. On the third day of this, after his extubation, a MICU resident who had spent time on toxicology recommended that theMICU consider buprenorphine to facilitate the wean from opioids and suggested they call for a consult to provide recommendations American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 6


egarding when and how to restart the buprenorphine and to weigh-in on whether it would be reasonable to use it to facilitate a weanfrom the fentanyl. Additionally, the family had been particularly concerned about the use of opioids in the hospital as they thought thatperhaps the patient might have recurrence of his addiction –they had been particularly dramatically effected from a financial andinterpersonal standpoint when he’d been active in his addiction and had seen how useful the buprenorphine had been during histreatment and successful maintenance over the past two years.The initial toxicology assessment and chart review took approximately 120 minutes (Level 5 consult -99255 which isn’t included in thereimbursement information below). After the first interaction, which involved the H & P, the buprenorphine induction was fairly simple.I had the hospital hold patient’s fentanyl at midnight which had been consisting of fentanyl 50-100 mcg increments IV every 2-3 hoursduring the afternoon and we briefly had dexmedetomidine started (Precedex(TM)) to attenuate any withdrawal symptoms and provideanxiolysis as the patient was still in the ICU. Oral clonidine would have probably sufficed along with some lorazepam IV. The followingmorning I came at 0800 to confirm that no fentanyl or other opioids had been given, to perform the Clinical Opioid Withdrawal Scale(COWS) and to order the buprenorphine (as Suboxone ½ of one of the 8/2 mg strips). The Suboxone was administered sublingually, Icame back in 60 minutes and confirmed the patient was doing fine and then later in the day to check on him after his second dose.In addition to the Suboxone induction I was able to counsel the patient for smoking cessation. Smoking cessation is now reimbursedquite readily. For a 3 minute investment of time, which in this patient addressed one of the underlying primary medical issues not tomention directly contributing to his hospitalization, respiratory failure and intubation, I was reimbursed –more importantly the patienthad the importance of smoking cessation reinforced and he left the hospital with much better understanding about variouspharmacotherapies for tobacco cessation, with particular interest in varenicline (Chantix) and would be looking into this as smokingcessation therapy from his addiction psychiatrist and/or PCP (while using nicotine patches).The Addiction Psychiatrist would be continuing the Suboxone. He was particularly happy that someone was able to help manage thepatient’s medications during the hospital stay and help transition him effectively back onto the buprenorphine for discharge.Reimbursement for a single days consult related to f/u visit (99233), Suboxone induction (H0033) and Tobacco cessation (99406) was asfollows:1.) f/u (subsequent visit) consult codes: 99233 (35 minutes of bedside assessment as subsequent visit x 3) which was billed at$295.00 and reimbursed at $150.522.) Buprenorphine (Suboxone) induction: H0033 was billed at $248.00 and reimbursed at $225.003.) Tobacco Cessation: 99406 which was billed at $40.00 and reimbursed at $18.09.The total bill for medical toxicology consultation on a single day related to the above services came to $585.00 charged to his insuranceand $393.61 paid (collected by my department) from his insurance. The buprenorphine induction was reimbursed at above 90% ofamount charged.The statement can be seen here.Return to Table of ContentsACMT Forum FeaturesHoward Greller, MD, FACMTACMT Forum ModeratorHave you signed up for immediate notification of forum postsyet?This new feature gives you the ability to be immediately notifiedof posted messages in real time and you can select which forumsyou'd like to receive these immediate email messages from.You will still be able to receive either the daily or weekly digestin addition to the immediate emails. If you choose to receivethese immediate notifications, the links contained therein will logyou in automatically to the system. Please keep in mind that theposts still need to be moderated, and that this will increase thenumber of emails you receive from the website.Watch this brief 2 minute video showing how to activate theimmediate notification settings for the Forum.Please do not hesitate to contact me if you have any comments,questions or concerns. It is your feedback that allows us tocontinue to improve this service for the College, and directly ledto the upgrades seen here.Thank you for continuing to use the Forum.Return to Table of Contents American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 7


Oh The Places You Could Go...- Kathryn Kopec, DO – ACMT Board of Directors Intern“Okay, Kathy so you have a 36-year-old male who was outwalking at dusk outside of Brisbane and is bit on his right ankleby a “brown” snake. What was it, what do you want to know,and what do you do?” This was one of the first case questionsasked to me by Dr. Armstrong of the Western AustraliaToxicology department during my three week rotation lastwinter. Taipan, Brown, Red-bellied black, Death Adder, Tiger…all these went racing through my head, but I knew nothing aboutthem. All I was use to was the Eastern Diamondback and I wassure that was not the correct answer. I know I got the questionwrong, but after all, that is what I came here for, to learn abouttoxinology in the deadliest place on earth.With such a wide array of things to learn during fellowship it canbe overwhelming. Often when you are reading about things thatyou have not seen clinically it is hard to make a connection.Spitting cobra exposures? Box jellyfish stings? Arsenic toxicity?Funnel web spiders? Parathion ingestions? I live in Philadelphia,and while I adore the city of brotherly love, there are many toxrelated health concerns I am never going to see here. This led meto my proposal with my fellowship, perhaps could I go to wherethese things were really occurring to learn about and experiencethem first hand. ACMT has asked I share a little about myexperiences with you here. I have included some inserts from theemails I sent back home along the way.First, I had the opportunity to travel to Australia and work withthe Western Australia Toxicology department and Poison Center.Rounding with the toxicologists in Perth, Australia andreviewing cases from all over the country daily was an eyeopening experience; not just to the variety of toxicologicexposures, but to differences in management and treatmentpatterns. “…highlight case of the day was the massiveamlodipine and citalopram overdose who was intubated in theICU. She was maxed out on epi and levophed, onhyperinsulinemic euglycemia and a propofol drip. I swear that ifyou breathed in her direction, she started having clonus.”Then I participated in the Australian Toxinology Course which isoffered every other year in Adelaide. It is a weeklong intensivecourse covering snakes across the world, marine toxinology,arthropods, spiders, and plant toxicity. “…nothing like endingthe day with some safe Australian snake handling. So, theybrought in brown snakes, tiger snakes, red-bellied black snakes,and death adders and dropped them on the floor. ‘this is howyou would pick one up… or if one gets in your ED you cancorner it like this’ I did not pick them up. Let’s be honest, I stoodon a desk. It was pretty cool though. They did not bring in thetaipans as and I quote "they are just too dangerous to drop on thefloor with all of you." “I asked about getting a cone snail -apparently it is illegal to transport them out of Australia... but Iam working on it. =)”To continue the experience of learning first hand, I was fortunateenough to spend two and half weeks in Sri Lanka this pastNovember at two sites associated with the South Asian ClinicalToxicology Research Collaboration (SACTRC.) “…Indeed onetuk tuk ride and an 8-hour train ride later, I was welcome by 98%humidity, 95-degree heat that promptly turned and torrentiallydown-poured on me. I have been perhaps at times known to be awild driver, perhaps stopping at the last second, speeding, but Ihave nothing on these guys. They are by far the craziest drivers Ihave yet to see. It is hilarious the moves they will pull, especiallythe tuk tuks who honestly believe they own the road. Lanemarkers – merely suggestions not guidelines. You honk foreverything – “hey I am on your left” “hey I am coming through”“hello” “hey see the white girl walking on the side of road” andif another vehicle does respond to your honk you only honkmore and louder. It is a test of faith every time I get into one ofthese vehicles. Death at times seems imminent.”The main goal was to learn about the presentation andmanagement of organophosphate poisoned patients. Add on acollection of yellow oleanders patients, Russell viper bites, kraitbites, and plenty of paracetamol overdoses to be managedwithout laboratory data or often NAC treatment and it was anoverwhelming experience. “They have a separate poisoningward here, # 17 – which has bed space for 20 patients, thatincludes a separate ICU section (3 beds with cardiac monitoringand ventilator capability) within it. That is where I spend mostof my time.” “I am not sure I will forget that smell of my first OPoverdose patient.”Being able to see the clinical research being done in this countryby amazing researchers in our field was an incredible experience.Amazed with the continued presence and amount oforganophosphates, carbamates, herbicides poisonings that I seedaily, I questioned “how readily accessible are these?” Field triptime – welcome to the pesticide shop! From the outside it lookedlike a usual street store, but you walk into the back and there isan entire wall of carbamates, organophosphates, glyphosates,and other herbicides for my choosing. Here I am in a skirt andheels, obviously not a farmer and have no need for any of theseitems. I didn’t need a special license or a reason to buy them,there were no regulations on who could come in and purchasethem. Needless to say I took a lot of pictures and stronglycontemplated purchasing a small bottle just because…. then Ihad this image of me at customs trying to explain why I wastrying to bring banned chemicals that were potentiallyhazardous onto a plane and into the United States and thoughtmaybe this is not a good idea.There are so many amazing opportunities for medical toxicologyfellows and attendings internationally. The list of potential tripscould be endless … heavy metals in Southeast Asia, aluminumphosphide in the Middle East, organophosphates in SoutheastAsia, toxic alcohols on a weekly basis in Scandinavia,envenomation heaven in Australia….Continued on next page American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 8


Affiliate Membership – An IntroductionMichele Zell-Kanter, Pharm. D., DABATI decided to look back at previous ACMT Newsletters to get aflavor for their content, this being the “maiden” column forAffiliate Members. I was not prepared to see Michael Shannon’scolumn, as president of ACMT in 1999, on page 1 of the winternewsletter, and Paul Wax’s tribute to the late Michael Spadaforaon page 7. This was a sobering issue to say the least, but theCollege membership was inspiring, even in ACMT’s infancy.It is with this inspiration that I would like to introduce the newAffiliate Member category of the ACMT membership. AffiliateMembership is defined on the ACMT website as being availableto “licensed U.S. physicians who have an interest in medicaltoxicology and non-physicians who have a doctorate-leveldegree or ABAT certification and work in a field related tomedical toxicology”. To date there are 8 affiliate members: 6physicians and 2 doctors of pharmacy. A priority of ACMT is toattract highly qualified individuals who are actively involved intheir disciplines to join as Affiliate Members.I would like to provide some historical perspective on how Ibecame interested in ACMT. I work integrally with 4 ACMTmembers (including a Board member and a JMT Editorial Boardmember) and have been exposed to the College since itsinception. For years, the idea of becoming a member (whichwould also allow me to attend the ACMT pre-meeting symposiaat NACCT at the discounted rate) was intriguing and my interestin ACMT was piqued by the College’s seriousness andcommitment to high caliber teaching and improving patient care.My desire to become involved with ACMT was reinforced in2010, when I attended the first Joint American Israeli MedicalToxicology Conference in Haifa. Because the number of U.S.attendees was small it allowed for an intimate group to exchangeideas about their practices from across the world. I heardpresentations from physicians whose experiences are quitevaried from those with whom I work. I found it unfortunate thatI could not be more active in the College because I was not aphysician toxicologist.And so I am thrilled that ACMT has provided a pathway for usnon-physician toxicologists (and physician non-toxicologists!) tobecome members of the College. Our group of multi-talentedAffiliate Members has much to gain from ACMT, and in turn, theaffiliates have much to give to ACMT, with the ultimate goal ofproviding mutual education, improving upon the discipline ofMedical Toxicology, and positively impacting patient care.I hope that in future issues of this newsletter we will highlightindividual Affiliate Members to learn about their interests andexpertise. And I am greatly looking forward to attending theJoint American Israeli Medical Toxicology Conference April23-25, 2013, in Haifa, as an Affiliate Member!Return to Table of Contents2013 Joint American – Israeli Medical Toxicology ConferenceIn conjunction with the Israeli Society of Toxicology (IST), ACMT is proud to co-sponsor the joint Israeli-American MedicalToxicology Conference Type to be held to enter at the Rambam text Health Care Campus in Haifa, Israel on April 23-25, 2013.A top-notch faculty from the United States, Israel, Europe, and elsewhere have been assembled to provide cutting edge,clinically-relevant presentations in a historic venue. The previous conference in 2010 received outstanding reviews for itseducation content and inspiring experiences, and we look forward to this second conference.Watch the ACMT website here for more information.Puerto Rico,here we come!The Changing Faces of AntidotesMarch 15-17, 2013 San Juan Marriott Resort & Stellaris CasinoSan Juan, Puerto RicoMeeting AgendaDaily Platform Sessions and Posters with AuthorsExplore Puerto RicoIT’S NOT TOO LATE TO REGISTERALCOHOL ABUSEACADEMY:Current Perspectiveson Impairment,Dependence, andWithdrawalMarch 14, 2013Marriott Resort& Stellaris CasinoSan Juan, Puerto RicoMeeting AgendaClick here to register American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 11


Calendar of Events2013March 14" 2013 ACMT Alcohol Abuse Academy" " San Juan Marriott Resort & Stellaris Casino! ! San Juan, Puerto Rico! ! More Information" " Register Now (Alcohol Abuse Academy Only)March 15-17" 2013 ACMT Annual Scientific Meeting" " San Juan Marriott Resort & Stellaris Casino! ! San Juan, Puerto Rico! ! More Information" " Register NowMarch 21! Monthly National Case Conference! ! Online Webinar - Watch your email for meeting link! ! View previous National Case Conferences here! !April 9! ! Toxicology Expert Webinar! ! Online Webinar - Watch your email for meeting link! ! Guest Speaker: Leonard J. Paulozzi, MD, MPHApril 23-25! Israeli-American Medical Toxicology Conference! ! Rambam Health Care Campus! ! Haifa, Israel! ! More InformationApril 24"! JMT Peer Review Workshop Webinar! ! Online Webinar - Watch your email for meeting linkApril 30"! Chemical Agents of Opportunity for Terrorism:" " TICs & TIMs! ! Jacob K. Javits Federal Building! ! New York, NY! ! More Information! ! Register Now!May 28-31" EAPCCT Congress! ! Radisson Blu Scandinavia! ! Copenhagan, Denmark! ! More Information! ! Register NowNov 12-13" ACMT Seminars in Forensic Toxicology:" " Consultation in the Civil & Criminal Arenas! ! The Hilton Baltimore! ! Baltimore, MD! ! More Information! ! Registration Opening Soon!We want to hear from you! Please share with us anynews of yourself or ACMT colleagues and we’ll includeit in the next ACMT newsletter. We also welcomecomments and suggestions for future newsletters. Sendinformation to newsletter@acmt.net.Thank you - The EditorsJosef Thundiyil, MD, FACMT (joseft@mindspring.com)Lewis Nelson, MD, FACMT (lewis.nelson@acmt.net)Craig Smollin, MD (csmollin@gmail.com)Andrew Stolbach, MD (andrewstolbach@hotmail.com)ACMT Board of DirectorsSuzanne White, MD, FACMT - PresidentLewis Nelson, MD, FACMT - Past PresidentLeslie Dye, MD, FACMT - Vice PresidentCharles McKay, MD, FACMT - Secretary-TreasurerSteve Aks, DO, FACMTMichele Burns Ewald, MD, FACMTG. Patrick Daubert, MD, FACMTHoward Greller, MD, FACMTLouise Kao, MD, FACMTWilliam Russ Kerns, MD, FACMTEric Lavonas, MD, FACMTStephen Munday, MD, FACMTMichelle Ruha, MD, FACMTACMT StaffPaul Wax, MD, FACMT - Executive DirectorTricia Steffey - Executive AssistantJim Wiggins, MPH - Educational CoordinatorLynn Lancaster - Grant Manager/Grant WriterEric Smith - Information Technology AdministratorDONATE NOWClick here to learn more about theMedical Toxicology FoundationThe Medical Toxicology Foundation is a not for-profit charitable organizationaffiliated with the American College of Medical Toxicology and is intended toprovide ACMT members, the general public, and commercial sponsors with atax deductible mechanism to support Medical Toxicology. Your gift to theMedical Toxicology Foundation - a 501(c)(3) educational organization - istax-deductible to the fullest extent allowable by law. American College of Medical Toxicology 10645 N. Tatum Blvd. Suite 200-111 Phoenix, AZ 85028 Phone: (623) 533-6340 Email: info@acmt.net 13

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