BALTIMORE CONVENTION CENTER
BALTIMORE, MD • DECEMBER 4–6, 2008
Current Clinical Issues
in Primary Care
Harvard Medical School
The Johns Hopkins
University
School of Medicine
Under the Direction of
Sanjiv Chopra, MD, FACP
L. Randol Barker, MD, ScM, MACP
Mark D. Aronson, MD, MACP t Karen J. Carlson, MD t Michael T. Crocetti, MD
Frank J. Domino, MD t John A. Flynn, MD, MBA t John D. Goodson, MD
Harvey P. Katz, MD t David E. Kern, MD, MPH t Manish Kohli, MD, MPH, MBA
Ellen Long-Middleton, PhD, RN, FNP t Sharon P. O’Neill, JD, MSN, CRNP
Jane S. Sillman, MD t Gerald W. Smetana, MD
Sharon Steinberg, MS, RN, CS t Randy Wertheimer, MD
Director of Programs & Partner Relations: Tenley C. Young
Course Coordinator: Susan J. McFeaters
Faculty
Edward J. Benz, Jr., MD
Clifton O. Bingham, III, MD
Joanne Borg-Stein, MD
Karen E. Boyle, MD
Elizabeth A. Cristofalo, MD, MPH
Charles S. Day, MD
Michael I. Fingerhood, MD, FACP
Richard J. Gross, MD, ScM
Kenan E. Haver, MD
Jennifer A. Heller, MD, FACS
Melinda E. Kantsiper, MD
Edward K. Kasper, MD, FACC
Gerald S. Lazarus, MD
Bruce S. Lebowitz, DPM
Anthony J. Lembo, MD
Meredith B. Loveless, MD
Mark H. Lowitt, MD
Margaret R. Moon, MD, MPH
Enid R. Neptune, MD, FCCP
Louis Pasquale, MD
Duane S. Pinto, MD
Anne M. Rompalo, MD, ScM
Christopher D. Saudek, MD
Todd L. Savitt, PhD
Paul E. Segal, DO
Erica M. Sibinga, MD, MHS
C. Christopher Smith, MD
Barry S. Solomon, MD, MPH
Glenn J. Treisman, MD, PhD
Patrick T. Triplett, MD
Merolyn R. Winters, Interpreter
Coordinator
Mark T. Worthington, MD, AGAF
Roy C. Ziegelstein, MD, FACP
Susan J. Zieman, MD, PhD
Baltimore Convention Center t December 4–6, 2008
Copyright © 2008 President and Fellows of Harvard College
Welcome Letter
Dear Colleagues,
We are delighted to welcome each and every one of you to the 2008 Current Clinical Issues in Primary Care in
Baltimore. We, the Course Directors, and the entire faculty from two premier academic institutions sincerely feel
that it is a privilege for us to implement this outstanding educational endeavor for you. The reality is that we, in
turn, learn immensely from your questions and our many interactions with you.
The work you do is complex, challenging and of vital importance. This conference is a celebration of your
commitment to serve in direct patient care as well as your pursuit of new knowledge skills and the solidification
of previous foundations.
The topics we have chosen to present are relevant to our day to day practice and represent emerging trends that will
undoubtedly impact the practice of medicine in the months to come. Our speakers are seasoned clinician scholars
and speak from volumes of clinical experience. In addition, we request that our speakers offer concrete, evidencebased presentations and provide specific recommendations for generalist practitioners.
The clinicians who come to our conference do so from a wide range of generalist traditions. Our attendees include
practitioners from Family Medicine, Pediatrics and General Internal Medicine as well as the medical subspecialties.
We also have many nurse practitioners and physician assistants, as well as registered nurses who specialize in
generalist and specialty care.
We are confident that you will leave with an understanding of some of the most recent scientific advances, practical
pointers for the care of your patients and with a robust syllabus that you will likely refer to on many occasions in
the ensuing weeks and months.
This conference is also a wonderful opportunity for us to meet and talk with one another, share novel experiences
and make a renewed commitment to cherish all that is glorious and best about our profession.
The Course Development Committee
__________________________
Sanjiv Chopra, MD, FACP
Course Director
Harvard Medical School
Mark D. Aronson, MD, MACP, Deputy Director
Harvard Medical School
Karen J. Carlson, MD, Deputy Director
Harvard Medical School
Michael T. Crocetti, MD
The Johns Hopkins University School of Medicine
Frank J. Domino, MD
Harvard Medical School
John A. Flynn, MD, MBA
The Johns Hopkins University School of Medicine
John D. Goodson, MD, Deputy Director
Harvard Medical School
Harvey P. Katz, MD, Deputy Director
Harvard Medical School
David E. Kern, MD, MPH
The Johns Hopkins University School of Medicine
_______________________
L. Randol Barker, MD, ScM, MACP
Course Director
The Johns Hopkins University School of Medicine
Manish Kohli, MD, MPH, MBA
The Johns Hopkins University School of Medicine
Ellen Long-Middleton, PhD, RN, FNP
Harvard Medical School
Sharon P. O’Neill, JD, MSN, CRNP
The Johns Hopkins University School of Nursing
Jane S. Sillman, MD, Deputy Director
Harvard Medical School
Gerald W. Smetana, MD
Harvard Medical School
Sharon Steinberg, MS, RN, CS
Harvard Medical School
Ex-Officio Member
Randy Wertheimer, MD
Harvard Medical School
Current Clinical Issues in Primary Care
Thursday, December 4, 2008
Morning Sessions
8:00–9:00 a.m.
Welcome and Keynote Address
Welcome
Sanjiv Chopra, MD, FACP and L. Randol Barker, MD, ScM, MACP
Keynote Address
Sanjiv Chopra, MD, FACP, Moderator
The Changing Face of Cancer Research and Care
Edward J. Benz, Jr., MD
9:00–9:45
BREAK
9:45–11:45 a.m. Session 1: Challenges in Primary Care
9:45
10:25
11:05
9:45–11:45 a.m. Session 2: Geriatrics
9:45
10:25
11:05
Jane S. Sillman, MD, Moderator
The Eyes Have It!–Teleophthalmology: Coming to
a Town Near You
Primary Care Approach to Obesity
Osteoarthritis: Pathology, Clinical Aspects, Treatment
Louis Pasquale, MD
Jane S. Sillman, MD
Clifton O. Bingham, III, MD
L. Randol Barker, MD, ScM, MACP, Moderator
The Highs and Lows of Cholesterol
Management in Octogenarians and Beyond
HBP Treatment in Older Persons
Will the Elderly See 20/20 in the Year 2020
Susan J. Zieman, MD
L. Randol Barker, MD
Louis Pasquale, MD
9:45–11:45 a.m. Session 3: Cardiovascular Updates
Sharon P. O'Neill, JD, MSN, CRNP, Moderator
9:45
10:25
11:05
Angioplasty: A Reality Check
CHF Update
Work Up of Claudication
Duane S. Pinto, MD
Roy C. Ziegelstein, MD
Duane S. Pinto, MD
Afternoon Sessions
1:45–5:30 p.m.
1:45
2:30
3:15–4:00
4:00
4:45
1:45–5:30 p.m.
1:45
2:30
3:15–4:00
4:00
4:45
1:45–5:30 p.m.
1:45
2:30
3:15–4:00
4:00
4:45
Session 4: Women’s Health
Karen J. Carlson, MD, Moderator
Female Sexual Health: Function, Dysfunction,
and Enhancing Gratification
Prevention of Women’s Cancers
Karen E. Boyle, MD
Karen J. Carlson, MD
BREAK
Contraception: What's New in 2008
Venous Insufficiency in the 21st Century: New Perspectives
Jane S. Sillman, MD
Jennifer A. Heller, MD
Session 5: GI (Audience Response System)
Sanjiv Chopra, MD, FACP, Moderator
Irritable Bowel Syndrome
Case Presentations in Gastroenterology
Anthony J. Lembo, MD
Sanjiv Chopra, MD
BREAK
Inflammatory Bowel Disease
GERD
Mark T. Worthington, MD
Anthony J. Lembo, MD
Session 6: Medicine Potpourri
John A. Flynn, MD, MBA, FACP, FACR, Moderator
Perioperative Cardiovascular Evaluation and
Management for Noncardiac Surgery
Preoperative Pulmonary Evaluation
Edward K. Kasper, MD
Gerald W. Smetana, MD
BREAK
New Drugs for the Primary Care Provider: What
You Need to Know
COPD: Update for 2008
Gerald W. Smetana, MD
Enid R. Neptune, MD
Current Clinical Issues in Primary Care
Friday, December 5, 2008
Morning Sessions
8:00–9:00 a.m.
Keynote Address
Sanjiv Chopra, MD, FACP, Moderator
Honoring a Father's Dream: The Story of the Sons of Lwala
Milton Ochieng', MD and Frederick Ochieng'
9:00–9:45
BREAK
9:45–11:45 a.m. Session 7: Orthopedic Live Demonstration
John Goodson, MD and Gerald W. Smetana, MD, Moderators
9:45
10:45
Neck Examination
Foot Pain
Joanne Borg-Stein, MD
Bruce S. Lebowitz, DPM
9:45–11:45 a.m. Session 8: Challenges in Pediatric & Adolescent Medicine
Harvey P. Katz, MD, Moderator
9:45
10:25
11:05
Meeting the Challenges of Latino Health in the
21st Century: Focus on Pediatrics
Mind-Body Therapies for Children and Youth
Physical Medicine for Adolescents
Michael T. Crocetti, MD and Merolyn
R. Winters, Interpreter Coordinator
Erica M. Sibinga, MD
Joanne Borg-Stein, MD
Afternoon Sessions
1:45–3:15 p.m.
1:45
2:30
3:15–4:00
Session 9A: Behavioral Medicine
Manish Kohli, MD, MPH, MBA, Moderator
Buprenorphine: Management of Opiate Addiction
Non-Pharmacologic Treatment of Insomnia
BREAK
4:00–5:30 p.m. Session 9B: Psychiatry
4:00
4:45
1:45–5:30 p.m.
1:45
2:30
3:15–4:00
4:00
4:45
1:45–3:15 p.m.
1:45
2:30
3:15–4:00
4:00–5:30 p.m.
4:00
4:45
Michael I. Fingerhood, MD
Karen J. Carlson, MD
L. Randol Barker, MD, ScM, MACP, Moderator
Psychiatric Emergencies Presenting in the Office
Differential Diagnosis of Depression
Patrick T. Triplett, MD
Glenn J. Treisman, MD
Session 10: Specialties for the Pediatrician Harvey P. Katz, MD, Moderator
Primary Care for the NICU Graduate
Elizabeth A. Cristofalo, MD and
Barry S. Solomon, MD
Patient Safety and Telephone Medicine: Lessons Learned
Harvey P. Katz, MD
BREAK
Abnormal Uterine Bleeding in the Adolescent
Asthma Guidelines: What’s New?
Meredith B. Loveless, MD
Kenan E. Haver, MD
Session 11A: Recent Articles That Will Change Your Practice (ARS)
Mark D. Aronson, MD, MACP, Moderator
Recent Articles That Will Change Your Practice
Recent Articles That Will Change Your Practice
John D. Goodson, MD
Mark D. Aronson, MD
BREAK
Session 11B: Challenging Curbside Consults (ARS)
Mark D. Aronson, MD, MACP, Moderator
Challenging Curbside Consults in Hepatology
The Pre-Op Patient with More Than Cardio-Pulmonary Issues
Sanjiv Chopra, MD
Richard J. Gross, MD
Current Clinical Issues in Primary Care
Saturday, December 6, 2008
Morning Sessions
8:00–9:00 a.m.
Keynote Address
L. Randol Barker, MD, ScM, MACP, Moderator
Medical Readers’ Theater: Getting into Everybody’s Head
9:00–9:45
Todd L. Savitt, PhD
BREAK
9:45–11:45 a.m. Session 12: Orthopedic Live Demonstration
Mark D. Aronson, MD, FACP and Gerald W. Smetana, MD, Moderators
9:45
10:45
Physical Examination and Diagnoses of Hand and Wrist Pain
Assessment of the Painful Shoulder in the
Primary Care Setting
Charles S. Day, MD
C. Christopher Smith, MD
9:45–11:45 a.m. Session 13: Pediatric & Adolescent Puzzles: Interactive Problem Solving
(Audience Response System)
Michael T. Crocetti, MD, Moderator
9:45
10:25
11:05
Common Pediatric Airway Pathology
Challenging Patients in Pediatrics: What’s Your Diagnosis?
Everyday Ethics in Pediatrics: Cases and Questions
Kenan E. Haver, MD
Harvey P. Katz, MD
Margaret R. Moon, MD
Afternoon Sessions
1:45–3:45 p.m.
1:45
2:25
3:05
1:45–3:45 p.m.
1:45
2:25
3:05
Session 14: Key Updates on Common Conditions
David E. Kern, MD, MPH, Moderator
An Approach to Chronic Kidney Disease
The Practical Use of New Insulins in the Treatment
of Type 2 Diabetes
Major Developments in STDs in the New Millennium
Paul E. Segal, DO
Christopher D. Saudek, MD
Anne M. Rompalo, MD
Session 15: Session 15: Challenging Problems in Primary Care
L. Randol Barker, MD, ScM, MACP, Moderator
Comparing and Contrasting: Common Dermatologic Look-Alikes
Mark H. Lowitt, MD
Ongoing Care of the Cancer Survivor: An Evolving
Melinda E. Kantsiper, MD
Role for the Generalist
Cutaneous Ulcers: Clinical Challenges for Primary Care
Practitioners 2008
Gerald S. Lazarus, MD
Course Development Committee
The educational program "Current Clinical Issues in Primary Care" is developed by the Course Committee of
Harvard Medical School and The Johns Hopkins University School of Medicine. All decisions about the program
content and faculty are made exclusively by the Course Development Committee.
It is the mission of the Course Committee to develop, present, and promote an educational opportunity that is
timely, relevant, and of the highest quality. To that end, we welcome your comments about how to better serve
your needs.
HARVARD MEDICAL SCHOOL
THE JOHNS HOPKINS UNIVERSITY
SCHOOL OF MEDICINE
Sanjiv Chopra, MD, FACP
Course Director
Harvey P. Katz, MD
Deputy Director
L. Randol Barker, MD, ScM, MACP
Course Director
Faculty Dean for Continuing Education
Professor of Medicine
Harvard Medical School
Senior Consultant in Hepatology
Beth Israel Deaconess Medical Center
Harvard Medical School
401 Park Drive, 2nd Floor West
Boston, MA 02215
Associate Clinical Professor
Harvard Medical School
Director, Primary Care Clerkship
Co-Director, Division of Primary Care
Dept. of Ambulatory Care & Prevention
Harvard Pilgrim Health Care
133 Brookline Avenue, 6th Floor
Boston, MA 02215
Professor of Medicine
The Johns Hopkins University
School of Medicine
Mark D. Aronson, MD, MACP
Deputy Director
Ellen Long-Middleton, PhD, RN, FNP
John A. Flynn, MD, MBA, FACP, FACR
Assistant Professor
MGH Institute of Health Professions
36 1st Avenue
Boston, MA 02129
D. William Schlott Professor of Medicine and
Clinical Director
The Johns Hopkins University
School of Medicine
Jane S. Sillman, MD
Deputy Director
David E. Kern, MD, MPH
Professor of Medicine, Harvard Medical
School
Vice Chair for Quality, Department of
Medicine
Associate Chief, Division of General
Medicine & Primary Care
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215
Karen J. Carlson, MD
Deputy Director
Assistant Professor of Medicine
Harvard Medical School
Director, Women’s Health Associates
Massachusetts General Hospital
32 Fruit Street – Blake 10
Boston, MA 02114
Frank J. Domino, MD
Associate Professor & Clerkship Director
Family Medicine and Community Health
University of Massachusetts
Medical School
55 Lake Ave North
Worcester, MA 01655
John D. Goodson, MD
Deputy Director
Associate Professor of Medicine
Harvard Medical School
Physician, Massachusetts General Hospital
Wang Ambulatory Care Center–WAC 615
15 Parkman Street
Boston, MA 02114
Assistant Professor of Medicine
Harvard Medical School
Director, Primary Care Residency Program
Brigham and Women’s Hospital
45 Francis Street
Boston, MA 02115
Michael T. Crocetti, MD
Assistant Professor, Pediatrics
The Johns Hopkins University
School of Medicine
Professor of Medicine
The Johns Hopkins University
School of Medicine
Manish Kohli, MD, MPH, MBA
Johns Hopkins Community Physicians
The Johns Hopkins University
School of Medicine
Gerald W. Smetana, MD
Associate Professor of Medicine
Harvard Medical School
Division of General Medicine &
Primary Care
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215
Sharon Steinberg, MS, RN, CS
Lecturer, Ambulatory Care and Prevention
Harvard Medical School
Harvard Pilgrim Health Care
Ex-Officio Member
Randy Wertheimer, MD
Chair, Department of Family Medicine
Cambridge Health Alliance
Harvard Medical School
Sharon P. O’Neill, JD, MSN, CRNP
Assistant Professor of Nursing
The Johns Hopkins University
School of Nursing
Faculty
Edward J. Benz, Jr., MD
Richard and Susan Smith Professor of
Medicine
Professor of Pediatrics,
Professor of Pathology
Faculty Dean for Oncology
Harvard Medical School
President & CEO, Dana-Farber Cancer
Institute
Chief Executive Officer, DanaFarber/Partners CancerCare
Dana Farber Cancer Instititute
44 Binney St
Boston, MA 02115
Clifton O. Bingham, III, MD
Assistant Professor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
MFL Bldg., Center Tower
5200 Eastern Avenue, Suite 4100
Baltimore, MD 21224
Joanne Borg-Stein, MD
Assistant Professor of Physical
Medicine and Rehabilitation
Harvard Medical School
Medical Director, Spaulding-Wellesley
Rehabilitation Center
Chief, Physical Medicine and
Rehabilitation
Medical Director, Spine Center
Newton-Wellesley Hospital
Spaulding-Wellesley Rehabilitation
Center
65 Walnut Street
Wellesley, MA 02481
Karen E. Boyle, MD
Assistant Professor of Medicine
The Johns Hopkins University, School
of Medicine
Department of Medicine
Greater Baltimore Medical Center
6535 N. Charles St., Suite 625
Baltimore, MD 21204
Elizabeth A. Cristofalo, MD, MPH
Assistant Professor of Pediatrics
The Johns Hopkins University, School
of Medicine
Department of Pediatrics
Nelson 2 133
600 N. Wolfe Street
Baltimore, MD 21287
Charles S. Day, MD
Assistant Professor in Orthopedic
Surgery
Director, Orthopedic Curriculum
Harvard Medical School
Chief, Orthopedic Hand and Upper
Extremity Surgery
Director, Hand and Upper Extremity
Surgery Fellowship
Beth Israel Deaconess Medical Center
Orthopedic Surgery
330 Brookline Ave
Boston, MA 02215
Michael I. Fingerhood, MD, FACP
Associate Professor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
MFL Bldg., West Tower
5200 Eastern Avenue, 2nd Fl
Baltimore, MD 21224
Richard J. Gross, MD, ScM
Associate Professor of Medicine
The Johns Hopkins University School
of Medicine
Department of Medicine
Johns Hopkins White Marsh
4924 Campbell Boulevard
White Marsh, MD 21236
Kenan E. Haver, MD
Assistant Professor of Pediatrics
Harvard Medical School
Associate Pediatrician
Director, Pediatric Pulmonary
Fellowship Program
Massachusetts General Hospital
Pediatric Pulmonary
55 Fruit St
Boston, MA 02114
Jennifer A. Heller, MD, FACS
Assistant Professor of Surgery
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Surgery
A5C
4940 Eastern Avenue
Baltimore, MD 21224
Melinda E. Kantsiper, MD
Instructor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
MFL Bldg., West Tower
5200 Eastern Avenue, CIMS Suite
Baltimore, MD 21224
Edward K. Kasper, MD, FACC
Professor of Medicine
Chief of Clinical Cardiology
The Johns Hopkins University School
of Medicine
Division of Cardiology
Blalock 536A
600 N. Wolfe Street
Baltimore, MD 21287
Gerald S. Lazarus, MD
Professor of Dermatology
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
MFL Bldg., Center Tower
5200 Eastern Avenue, Suite 2500
Baltimore, MD 21224
Bruce S. Lebowitz, DPM
Instructor of Orthopaedics
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Orthopedics
A6C
4940 Eastern Avenue
Baltimore, MD 21224
Anthony J. Lembo, MD
Assistant Professor of Medicine
Harvard Medical School
Director, GI Motility Center
Beth Israel Deaconess Medical Center
Gastroenterology, DA 501
330 Brookline Ave
Boston, MA 02215
Meredith B. Loveless, MD
Assistant Professor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Ob/Gyn
A1C-125
4940 Eastern Avenue
Baltimore, MD 21224
Faculty
Mark H. Lowitt, MD
Clinical Associate Professor of
Dermatology
University of Maryland School of
Medicine
Greater Baltimore Medical Center
Suite Ppe 315
6565 N. Charles Street
Baltimore, MD 21204
Margaret R. Moon, MD, MPH
Assistant Professor of Pediatrics
The Johns Hopkins University School
of Medicine
Department of Pediatrics
Rubenstein Bldg., Rm 2060
200 N. Wolfe Street
Baltimore, MD 21287
Enid R. Neptune, MD, FCCP
Assistant Professor of Medicine
The Johns Hopkins University School
of Medicine
Department of Medicine
5th Floor
1830 E. Monument Street
Baltimore, MD 21205
Louis Pasquale, MD
Assistant Professor of Ophthalmology
Harvard Medical School
Co-Director, Glaucoma Service
Massachusetts Eye and Ear Infirmary
Research Director, Ocular Telehealth
Center
Boston VA Hospital
Massachusetts Eye & Ear Infirmary
Ophthalmology
243 Charles St.
Boston, MA 02114
Duane S. Pinto, MD
Assistant Professor of Medicine
Harvard Medical School
Director, Cardiology Fellowship
Training Program
Beth Israel Deaconess Medical Center
Interventional Cardiology
1 Deaconess Road
Boston, MA 02215
Anne M. Rompalo, MD, ScM
Professor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Infectious Disease
MFL Bldg., Center Tower
5200 Eastern Avenue, Suite 4000
Baltimore, MD 21224
Christopher D. Saudek, MD
Hugh P. McCormick Family Professor
of Endocrinology and Metabolism
The Johns Hopkins University School
of Medicine
Department of Endocrinology
Osler 576 Endocrinology
600 N. Wolfe Street
Baltimore, MD 21287
Todd L. Savitt, PhD
Professor of Medical Humanities
Brody School of Medicine
Department of Medical Humanities
East Carolina University
600 Moye Boulevard
Greenville, NC 27834
Paul E. Segal, DO
Instructor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
B2N-208
4940 Eastern Avenue
Baltimore, MD 21224
Erica M. Sibinga, MD, MHS
Assistant Professor of Pediatrics
The Johns Hopkins University School
of Medicine
Department of Pediatrics
Park 351
600 N. Wolfe Street
Baltimore, MD 21287
C. Christopher Smith, MD
Assistant Professor of Medicine
Harvard Medical School
Associate Firm Chief, Herrman
Blumgart Medical Firm
Associate Director, Internal Medicine
Residency Program
Beth Israel Deaconess Medical Center
Co-Director, Rabkin Fellowship in
Medical Education
Beth Israel Deaconess Medical Center
& Harvard Medical School
Beth Israel Deaconess Medical Center
Healthcare Associates - Shapiro 1
330 Brookline Avenue
Boston, MA 02215
Barry S. Solomon, MD, MPH
Assistant Professor of Pediatrics
The Johns Hopkins University School
of Medicine
Department of Pediatrics
Room 2074
200 N. Wolfe Street
Baltimore, MD 21207
Glenn J. Treisman, MD, PhD
Professor of Psychiatry
The Johns Hopkins University School
of Medicine
Department of Psychology
Meyer 119
600 N. Wolfe Street
Baltimore, MD 21287
Patrick T. Triplett, MD
Assistant Professor of Psychiatry
The Johns Hopkins University School
of Medicine
Department of Psychiatry
Meyer 279
600 N. Wolfe Street
Baltimore, MD 21287
Merolyn R. Winters, Interpreter
Coordinator
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Patient Services
4940 Eastern Avenue
Baltimore, MD 21224
Faculty
Mark T. Worthington, MD, AGAF
Associate Professor of Medicine
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
Room A501
4940 Eastern Avenue
Baltimore, MD 21224
Roy C. Ziegelstein, MD, FACP
Professor of Medicine
Exec Vice Chair, DOM
Deputy Director for Education
The Johns Hopkins University, Johns
Hopkins Bayview Medical Center
Department of Medicine
4940 Eastern Avenue
Baltimore, MD 21224
Susan J. Zieman, MD, PhD
Assistant Professor of Medicine
The Johns Hopkins University School
of Medicine
Department of Medicine
JH Heart Health Timonium
110 W. Timonium Road, Suite 2C
Timonium, MD 21093
Faculty Disclosure Statement
Harvard Medical School has long maintained the standard that its continuing medical education programs be free of
commercial bias.
In accordance with the disclosure policy of the Medical School, as well as standards set forth by the Accreditation
Council on Continuing Medical Education, speakers have been asked to disclose any relationship they have to companies
producing pharmaceuticals, medical equipment, prostheses, etc. that might be germane to the content of their lectures.
Please note that in accordance with recent policies from the ACCME, relationships of the person involved in the CME
activity must include financial relationships of a spouse or partner. In addition, faculty have been asked to list any uses
they will discuss of pharmaceuticals and devices for investigational or non-FDA approved purposes.
These disclosures are not intended to suggest or condone bias in any presentation, but are elicited to provide registrants
with information that might be of potential importance to their evaluation of a given talk.
The following speakers have reported receiving something of value* from a company whose product may be germane to the
content of their presentations:
Mark D. Aronson, MD, MACP
Clifton O. Bingham, III, MD
Editor (royalties): UpToDate
Consulting: Abbott, Amgen, Cypress Bioscience, Genentech, Merck, Novartis, Roche,
Targeted Genetics, UCB
Contracted research: Bristol-Myers Squibb, Genentech, Wyeth
Educational/Grant support: Abbott, Amgen, Bristol-Myers Squibb, Centocor,
Genentech,
Sonosite, Procter & Gamble
Sanjiv Chopra, M.D.
Royalty: UpToDate
Speakers’ bureau: Schering-Plough, Roche
Anthony J. Lembo, MD
Consultant: Ironwood, Takeda/Sucampo, Prometheus Labs
Advisory board: Wyeth
Meredith B. Loveless, MD
Speakers’ bureau: Merck
Louis Pasquale, MD
Consultant: Innovation Factory, Meda Corp., Pfizer, Allergan, Alcon Labs
Research support: Department of Defense, National Institute of Health
Speaker: Alcon Labs
Anne M. Rompalo, MD, ScM
Speakers’ bureau: GlaxoSmithKline, Merck
Christopher D. Saudek, MD
Advisory board: GlaxoSmithKline
Glenn J. Treisman, MD, PhD
Speaker: Boehringer Ingelheim, Abbott
Mark T. Worthington, MD, AGAF Speaker: Abbott
The following speakers have reported receiving nothing of value* from a company whose product may be germane to the
content of their presentations:
L. Randol Barker, MD, ScM,
MACP
Karen E. Boyle, MD
Karen J. Carlson, MD
Elizabeth A. Cristofalo, MD, MPH
Michael T. Crocetti, MD
Charles S. Day, MD
Frank J. Domino, MD
Michael I. Fingerhood, MD, FACP
John A. Flynn, MD, MBA
John D. Goodson, MD
Richard J. Gross, MD, ScM
Eon C. Harry
Jennifer A. Heller, MD, FACS
Melinda E. Kantsiper, MD
Edward K. Kasper, MD, FACC
Harvey P. Katz, MD
David E. Kern, MD, MPH
Manish Kohli, MD, MPH, MBA
Gerald S. Lazarus, MD
Bruce S. Lebowitz, DPM
Susan J. McFeaters
Ellen Long-Middleton, PhD, RN
Mark H. Lowitt, MD
Margaret R. Moon, MD, MPH
Enid R. Neptune, MD, FCCP
Sharon P. O'Neill, JD, MSN, CRNP
Duane S. Pinto, MD
Todd L. Savitt, PhD
Paul E. Segal, DO
Erica M. Sibinga, MD, MHS
Jane S. Sillman, MD
Gerald W. Smetana, MD
C. Christopher Smith, MD
Barry S. Solomon, MD, MPH
Patrick T. Triplett, MD
Merolyn R. Winters
Tenley C. Young
Roy C. Ziegelstein, MD, FACP
Susan J. Zieman, MD, PhD
* “Something of value” refers to an equity position, receipt of royalties, consultantship, funding by a research grant,
receiving honoraria for educational services elsewhere, or to any other relationship to a company that provides sufficient
reason for disclosure, in keeping with the spirit of the stated policy.
Edward J. Benz, Jr., MD – TCY will email
Joanne Borg-Stein, MD – emailed, no resp.
Kenan E. Haver, MD - emailed
Harvard Medical School gratefully
acknowledges its contractual agreement
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Current Clinical Issues
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Buprenorphine: Management of Opiate Addiction
Michael I. Fingerhood, MD, FACP
Learning Objectives:
Associate Professor of Medicine
The Johns Hopkins University, Johns Hopkins
Bayview Medical Center
· To describe the evolution of opiate addiction
treatment.
· To define the prevalence and impact of
opiate addiction in the United States.
· To outline the use of buprenorphine in the
primary care setting.
Notes:
Michael Fingerhood MD
Buprenorphine: Management
for Opiate Addiction
Michael Fingerhood MD FACP
No Relevant Financial Relationships with
Commercial Interests
Objectives
Some faces of opioid
dependence
1. To define the prevalence and impact of
opioid dependence
2. To describe the evolution of opioid
dependence treatment
3. To outline the use of buprenorphine in
the primary care setting
Kim
11/10/05
11/10/05-- referred after “detox” for
continued tx with buprenorphine and for
ongoing primary care
Many detox in pastpast- no prolonged
abstinence; still dabbling in cocaine
“Want to get my life together”
Kim
Complaining of RUQ painpain- told in past viral
studies negative
Sono-- liver mildly enlarged; Hepatitis C antibody
Sono
positive; genotype 1A, VL
VL-- 154K; bx
bx--periportal
fibrosis
2/06-- Adherent with buprenorphine; no use of
2/06
opiates; binging on crack cocaine; told needed to
hold off on hepatitis C treatment
3/06 – “My life is a mess” - rollercoaster from
crack cocaine; agreed to NA, drug counseling and
psychiatric counseling
Kim
Opium History
5/06- Doing much better5/06better- working 40 hour/ week
job, in counselling 3x/week; drug screens all
negative; on stable dose of buprenorphinebuprenorphine- “I am
ready to start hepatitis C treatment”
Initiated 48 weeks of treatment. Seen initially
every week, then every 2 weeks, then every 4
weeks. (viral load negative at 12 weeks).
Successfully cleared hepatitis C virus
Continues doing well on buprenorphinebuprenorphine- no
relapses; no cocaine use
First cultivation of opium poppies was in
Mesopotamia, approximately 3400 B.C.,
plant called Hul Gil,
Gil, the "joy plant”
The Greek gods Hypnos (Sleep), Nyx
(Night) and Thanatos (Death) were
(Night),
depicted wreathed in poppies
The Persian physician, al
al--Razi (845
(845--930
A.D.) made use of opium in anesthesia and
recommended its use for the treatment of
melancholy.
Opium History
Between 400 and 1200 AD, Arab traders
introduced opium to China.
14th century Ottoman EmpireEmpire-opium used
to treat headache and back pain.
p
th
15 century ChinaChina- first officially recorded
use of opium as a recreational drug.
18741874- heroin developed
18981898-heroin marketed by Bayer as safe
pediatric cough suppressant
Abuse Potential
Degree of μ agonist activity
– Greater μ agonist activity ⇒↑abuse
⇒↑abuse potential
Route of administration
– Faster route ⇒↑abuse
⇒↑abuse potential
Injecting IV > Injecting SQ > Oral
Drug Half life
– Shorter halfhalf-life ⇒↑abuse
⇒↑abuse potential
Heroin > methadone
Opiates & Opioids
Opiates = naturally present in
opium
e.g. morphine, codeine, thebaine
Opioids = manufactured
Semisynthetics are derived from
an opiate
– heroin from morphine
– buprenorphine from thebaine
Synthetics are completely man
man-made to work like opiates
– methadone
Narcotic Regulation in US
1914
1914-- Harrison Narcotics Tax Act
1925
1925-- Linder vs United States
1964
1964-- Methadone introduced as
experimental
i
treatment for
f opioid
i i addiction
i i
1968
1968-- Bureau of Narcotic and Dangerous
Drugs formed (changed to DEA in 1973)
Narcotic Regulation in US
19701970- Controlled Substances Act
19741974- Narcotics Treatment Act
Act-- DEA
regulation of treatment (methadone)
19931993- LAAM approved for treatment
(removed for cardiac toxicity in 2003)
Traditional 12 Step Drug
Treatment
1. Accepting powerlessness
2. Disease identification
3. Surrender to a Higher Power
4. Commitment to AA/NA
5. Commitment to abstinence
6. Sober social support
7. Intention to avoid high-risk situations
Rationale for
Opioid Replacement Therapy
“Stabilize neuronal circuitry”
– Use drug that is cross
cross--tolerant, long
long--acting and
oral
– Have μ occupation/blockade effect
– Prevent or attenuate euphoric effect
Prevent withdrawal and craving
Prevent injection drug use
Prevent criminal activity
Effective Treatment of Opiate Addiction
NIH Consensus Development Conference
November 1717-19, 1997
ƒ Opiate dependence is a brainbrain-related medical
disorder
ƒ Treatment is effective
ƒ “Although
“Alth
had
drug-free
drugf
state
t t represents
t an optimal
ti l
treatment goal, research has demonstrated that this
goal cannot be achieved or sustained by the majority of
opiate--dependent people.”
opiate
ƒ Reduce unnecessary regulation of all longlong-acting
agonist treatment programs
ƒ Improve training of health care professionals in
diagnosis and treatment of opiate dependence
Opioid dependence in US 1999
>810,000 chronic opioid users
Rising problem of prescription opioid abuse
Detoxification is of limited longlong-term
effectiveness
180,000 methadone slots/patients
Access to treatment limited
Heroin-associated medical, lost earnings,
and illegal activity costs total $20 billion per
year in the United States
Baltimore 2000
2000--2003
Estimated 30,00030,000- 50,000 individuals with
opiate dependence
Baltimore first in the nation in perper-capita
heroin use
DEA estimated at least $1.5 million in cash
is exchanged every day during streetstreet-level
drug deals
Over 80% of city homicides related to
drugs.
Drug Addiction Treatment Act
of 2000 (DATA 2000)
Amendment of Controlled Substances Act
Signed
g
byy President Clinton October 2000
Allows prescription of “certain narcotics” to
treat addiction
DATA 2000 Restrictions
30 patients per prescriber
– Amended to allow request for 100 per
prescriber after first year
p
y
– No patient limit in opioid treatment
programs
Problems With Methadone
Treatment System
Reaches < 20% of potential eligible pts
– Stigma limits acceptability (prescription drug
abusers)
– NIMBY limits availability
Geographically concentrates patients
Highly regulated doses & take homes
Criteria exclude persons under age 18
DATA 2000 Restrictions
Physician Training
Certified in addiction medicine or addiction
psychiatry; OR
Participated in clinical trials; OR
8 hours of training in opiate addiction by
specified organizations:
– AMA, AAAP, ASAM, AOAAM, APA
DATA 2000 Restrictions
Medications Allowed
Must be Schedule III, IV, or V
– Methadone is Schedule II
M tb
Must
be approved
db
by FDA ffor use iin
treating addiction
– Subutex ® and Suboxone ® are the
ONLY approved medications
Buprenorphine’s Properties
Modest μ agonist activity with ceiling
Long half life
Precipitated withdrawal if taken after full
agonist
Decreased risk of respiratory, CNS depression
Sublingual route of administration
“Combo” tablet with naloxone limits abuse by
injection
Change In Approach
Methadone Clinic
– Slow gains
Anticipated Uses
Services must be
“available”
Buprenorphine, Methadone, LAAM:
Treatment Retention
First choice for young opioidopioid-dependent persons
100
Percent Re
etained
Successful methadone patients
People who do poorly with abstinenceabstinence-based
People who reject methadone treatment
People whose medical insurance will not cover
methadone (Medicare)
Communities in which methadone not available or
limited availabilty
Criteria:
– DSM IV
– No time criteria
MD sets dose
Age > 16
Take homes
– Up to 30 days
Required services
Reaching 600,000+ Untreated
– Moderate/short dependence (oral/snort/smoke)
– Easier transition to drug
drug--free treatment
Office--Based Bup/Nal
Office
Criteria:
– Withdrawal
– 12 months use
Dose regulated
Age > 18
Limited take homes
73% Hi Meth
80
60
58% Bup
40
53% LAAM
20
20% Lo Meth
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Study Week
Buprenorphine – methadone:
treatment retention
Johnson RE, et al (2000)
Buprenorphine Safety
No alteration of cognitive functioning
100
– feel “normal”
90
80
No organ damage
Perce
ent
70
60
50
40
30
Buprenorphine
20
Methadone
10
0
1 2
4
6
8
10
12
14
16
Week
(adapted from Strain et al., 1994
– Early concern of hepatic toxicity unconfirmed
– No evidence of QT prolongation
Ceiling prevents respiratory depression, OD
(Overdose reports with combining use with
benzodiazepines)
No clinically significant interactions with other
drugs
Appropriateness for OfficeOffice-based
Treatment
Use of buprenorphine
– Dependence on high doses of benzodiazepines,
alcohol, or other CNS depressants
– Significant psychiatric co
co--morbidity
– Multiple previous treatments (methadone)
Instruct patients to abstain from any opioid use
for 12
12--24 hours (so they are in mild withdrawal at
time of first buprenorphine dose)
Average
g dailyy dose is between 8/2 and 24/6 mg
g of
buprenorphine/naloxone
Aim for stable dose by day 3 or 4
Cost of buprenorphine/naloxone $7 per 8/2 tablet
Some insurance coverage bureaucracy
How we do it
Who were the first patients?
Patient is less likely to be an appropriate
candidate for officeoffice-based treatment:
Addiction Physician Survey 2003
Percent of Patien
nts Trea
Combine with primary care
Treatment contract
Counseling/Use
g
of 12 step
p meetings
g
Urine testing
Prescription rules
60%
50%
40%
30%
20%
10%
0%
New to Substance New to Medication- Transitioned from
Abuse Treatment Assisted Treatment
Methadone
Primary Care Buprenorphine:
Predictors of Retention
Addicted to NonHeroin Opioids*
Summary
Stein, Cioe & Friedmann. J Gen Intern Med. 2005
0.40
0.60
0.8
80
78%
0.20
Proportion Retaine
ed
1.00
Week 1 Urine Opiate Screen
Negative
Positive
18%
0
135 patients
63% heroin
– 50% IDU
180180-day retention, 58%
– Week 1 Urine Opiate
Tox.
– Employment (30%
vs. 73%)
– Any counseling (7%
vs. 52%)
0
30
60
90
Days
120
150
180
Office based treatment of opiate
dependence with buprenorphine
can/will revolutionize opiate drug
treatment in motivated individuals
Buprenorphine treatment must be
provided carefully and appropriately
Reward is great for both patient and
provider
Non-Pharmacologic Treatment of Insomnia
Karen J. Carlson, MD
Deputy Director, Harvard Medical School
Course Development Committee
Assistant Professor of Medicine, Harvard
Medical School
Director, Women’s Health Associates,
Massachusetts General Hospital
Deputy Director, Harvard Medical School
Center of Excellence in Women's Health
Learning Objectives:
· To understand basic sleep physiology
· To know the evidence for effectiveness of
nonpharmacologic and pharmacologic
treatment of chronic insomnia
· To understand cognitive and behavioral
factors that cause insomnia
· To develop an approach to using cognitive
and behavioral interventions in the primary
care setting
Notes:
Record Sales of Sleep Pills Cause Worry
NONPHARMACOLOGIC TREATMENT
OF INSOMNIA:
AN APPROACH FOR PRIMARY CARE
KAREN CARLSON, MD
MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL
Behavioral therapy is superior to
pharmacologic therapy in the
management of insomnia.
Behavioral therapy can be delivered
effectively in the primary care setting.
How does temporary sleep
disruption turn into chronic
insomnia?
z
z
Ongoing stress and trauma can lead
to p
permanent disruptions
p
in routine
of daily behaviors including sleep
Chronic insomnia most often caused
by changes in thoughts and
behaviors
The New York Times
February 7, 2006
by Stephanie Saul
Americans are taking sleeping pills like
never before, fueled by frenetic workdays
that do not go gently into a great night's
sleep, and lulled by a surge of consumer
advertising that promises safe slumber
with minimal side effects.
Our Agenda
Basics of sleep physiology
z Evaluation of insomnia
z Pharmacologic therapy
z Cognitive and behavioral therapy in
the primary care setting
z
Diagnosis of Insomnia
Based on perceived disturbance in
daytime functioning, not hours slept
z Patterns of insomnia
z
– Sleep initiation
– Sleep maintenance
z
Feeling of insufficient sleep
– Tiredness, difficulty concentrating, irritability
– Preoccupation with somatic complaints
z
Population prevalence 10%; more
common in women and elderly
The Sleep Cycle
Body Temperature
Body temperature varies over day
z Lowest in early morning about 4 AM
z Increases just before sun rises
z Increases all day until mid-afternoon
dip
z Peaks at 6:00 PM
z Drops after 6:00 PM
z
Characteristics of Insomniacs
Sleep Changes over Life Cycle
Greater physical tension
Greater brain activity
z Smaller changes in body
temperature
z Initiation problems:
temperature drops later
z Maintenance problems:
smaller drops in
temperature in the night
z
Decreases from 8 hours in young
adulthood to 6 ½ hours in 70s
z Deep sleep decreases
z Awakenings increase
z
z
Evaluation:
Key Points in History and Exam
Chronology
Difficulty initiating vs. frequent
awakenings (or both)
z Specific symptoms around onset,
during sleep, during day
z Exam: obesity, crowded oropharynx,
short thick neck
z
z
Insomnia co-existing with
other conditions
Psychiatric disorders: depression,
anxiety, PTSD
z Pain
z Medical conditions, e.g. sleep apnea,
COPD, restless legs, menopause
z Caffeine, tobacco, alcohol, and other
substance abuse
z
Who should be referred for
a sleep study?
z
Excessive daytime sleepiness (>10 on
Epworth scale) with
– Obesity
– Loud snoring
– Witnessed apneic episodes
z
Insomnia for >6 months with no evidence
medical, neurologic, or psychiatric cause,
not responsive to behavioral or
pharmacologic treatment
Epworth Sleepiness Scale
0 = would never doze 3 = high chance
Sitting and reading
Watching TV
Sitting inactive in public place
As passenger for an hour
Lying down during day
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In car, stopped for few minutes in traffic
Score > 10 = excessive daytime sleepiness
Medications for Insomnia:
FDA- approved
Benzodiazepines
Duration (T1/2)
triazolam
short (3-5 h)
temazepam
inter (8-15 h)
estazolam
inter (10-24h)
Benzodiazepine-receptor agonists
zaleplon (Sonata)
ultrashort (1 h)
zolpidem (Ambien)
short (3 h)
eszopiclone (Lunesta) inter (5-7 h)
Melatonin-receptor agonist
ramelteon (Rozerem) short (2-5 h)
Medications for Insomnia:
not FDA- approved
Cost*
$ 20
20
27
95
92
111
81
*wholesale pharmacy cost per month
Benzodiazepines
lorazepam
Duration (T1/2)
inter (12-15 h)
Peak
2h
Antidepressants
trazodone
doxepin
inter (5-9 h)
long (8-24 h)
1-2h
2-4h
Sparse evidence of efficacy for antidepressants in
primary insomnia
- RCT of 1, 3, 6 mg doxepin showed efficacy
without residual sedation (Roth T. Sleep 2007)
Thoughts and Behaviors
that Promote Insomnia
MOST INSOMNIA CAN BE
TREATED BY CHANGING
LEARNED THOUGHTS AND
BEHAVIORS
Worrying about going to sleep
Going to bed early and sleeping late
z Spending time in bed doing other
activities to get ready to sleep
z Alcohol and caffeine intake
z Reduced physical and mental activity
z Reduced exposure to sunlight
z
z
Evidence for effectiveness of
cognitive-behavioral interventions
z
z
Three meta-analyses: 70-80% of adults
with insomnia benefit from interventions
based on CBT1-3
RCT of zolpidem vs.
vs CBT in youngyoung and
middle-aged adults4:
– CBT alone equal or better than CBT+zolpidem
z
RCT of zopiclone vs. CBT in older adults5:
– CBT more effective than zopiclone in shortand long-term
1Morin CM Am J Psych 1994; 2 Smith MT Am J Psych 2002; 3 Cochrane
4 Jacobs GD Arch Intern Med 2004; 5 Sivertsen B JAMA 2006
Key components of insomnia
treatment in primary care
Lifestyle and environmental factors:
stimulus control
z Sleep restriction
z Cognitive restructuring
z Relaxation techniques
z
Long-term effectiveness of CBT alone
vs combination of CBT + drugs
CBT maintains effectiveness at up to 2
years but combined therapy does not1-3
z In patients on long-standing
long standing
benzodiazepines, use of CBT results in
higher rates of success in stopping drug
therapy4,5
z
1 Morin CM JAMA 1999 2 Jacobs GD. Arch Intern Med 2004 3 Hamill PJ
Sleep 1997 4 Baillargeon L. CMAJ 2003 5 Morin CM. Am J Psych
2004
Lifestyle and environmental
factors
Typical habits of insomniacs:
z Going to bed early
z Using bed for rest and relaxation, not just
sleep
z Not exercising because of fatigue
z Using alcohol to help get to sleep
Goal of interventions is stimulus control and
substitution of habits that promote good
sleep
Exercise improves sleep
• Exercise increases daily rise and fall in
z
z
•
•
body temperature and improves sleep
Drop in temperature improves sleep onset
Ph i l stress
Physical
t
off exercise
i increases
i
deep
d
sleep
Exercise more than three hours before
bed if possible
If unable to exercise, hot bath 2 hrs before
bed will promote temperature rise and fall
Light affects sleep
Lack of light increases melatonin,
causes body temperature to fall, and
promotes sleep onset
z Light decreases melatonin and causes
body temperature to increase, which
in turn promotes wakefulness
z
Sleep onset insomnia:
difficulty falling asleep
z
Body temperature
falls too late
z
Exposure to early
morning sunlight
associated with
earlier rise in body
temperature and
easier sleep onset
Stimulus control:
the bed as a signal for sleep
z
z
z
z
Keep sleeping area cool, dark, quiet
Use bed for sleep (and sex) only
Avoid stressful activities during hour
b f
before
bed
b d
Limit time spent in bed while awake:
improve sleep “efficiency”
sleep efficiency = time asleep
time in bed
goal: 85%
Sample sleep diary
Activity
Went to bed
Lights off
Fell asleep
?
Awake for ~1/2 hr
Awake for ~ 1 hr
Final wake up
Got out of bed
SLEEP EFFICIENCY:
Time
Sleep hours
11:00
11:15
12:00
2 h
2:00
1.5 h
4:00
2 h
7:00
7:30
_____
hours slept
5.5 h
hours in bed
8.5
65%
Sleep maintenance insomnia:
early morning awakening
z
Body temperature
falls too early
z
Increase exposure
to evening bright
light
The Sleep Diary
What time did you get to bed? Turn lights
off?
How long did it take to fall asleep?
H
How
many ti
times did you awaken?
k ?
How long awake for each one?
What time was final wake up? Time out of
bed?
How many hours did you sleep last night?
How many hours did you spend in bed?
Rx for Sleep Restriction
Reduce time in bed
Total time in bed = mean sleep
duration + ½ hour ((no less than 5 h))
If not asleep in 20 – 30 minutes, get up
and do something dull
Go back to bed when drowsy
When reach sleep efficiency of 85%,
increase sleep time
Sleep scheduling
Increases sleep drive through partial sleep
deprivation
z Regular rising time promotes good sleep
z Delay in arising leads to delay in exposure
to sunlight and activity, thus delay in rise
in body temperature
z Get up around same time, even after night
of poor sleep
Changing Negative Sleep Thoughts
z
z
z
Negative Sleep Thoughts
Fallacies about sleep
z
z
z
z
z
Often automatic
Often incorrect
Stir up
p negative
g
feelings
g and frustration
Negative feelings set off stress response
– Increase heart and respiratory rate
– Raise blood pressure
– Increase muscle tension
– Activate arousal system
Promoting Positive Sleep Thoughts
First step – identify negative sleep
thoughts
z Write down negative sleep thoughts
z Assess the distortions
z Replace with positive sleep thoughts
z
Most insomniacs worry excessively about
sleeping
Negative
g
thinking
g about sleep
p most
important contributor to insomnia
Changing negative thoughts about sleep
can have a significant effect on insomnia
z
z
z
Most people get more sleep than they
think
Most can function on 5 ½ hours of sleep
(core sleep) – even if interrupted
No evidence that health impaired by
decreased sleep if get core sleep
Main effect of sleep loss is on mood; most
studies of cognitive and motor function
show no consistent effect on loss of
alertness or performance
Negative
z
z
z
z
I will not fall asleep
tonight
I will be exhausted
in the morning
I’ve got to have 8
hours of sleep
I will get sick from
so little sleep
to Positive
z
z
z
z
I will fall asleep
sooner or later
I need less sleep
than I think
I can improve my
sleep
If I get my core
sleep, I’ll function
OK
Chronic Stress Response
Stress Response
z
z
Physiological changes associated with
arousal set off by fearful or stressful
situation
Increased heart rate, breathing, blood
pressure, muscle tension, brain waves,
blood glucose levels, energy, and
sensory acuity
z
z
z
z
Four Ingredients Associated with the
Relaxation Response
Relaxation Response
z
z
z
Identified by Dr. Herbert Benson
“Body’s inborn counterbalancing
mechanism to stress response”
Ph i l i l changes:
Physiological
h
- Decreased brain waves, breathing,
heart rate, blood pressure, stress
hormones
- Increased blood flow to extremities,
relaxation of muscles
Relaxation Response
z
z
z
Improves sleep by countering stress
response all day and decreasing
stress hormones day and night
Improves sleep by stopping negative
sleep thoughts when practiced at night
Produces brain waves similar to stage I
sleep
– the transition state
Interferes with
sleep
Reduced deep
p
sleep
Increased stress
hormones
throughout day
Wakefulness
system operating
day and night
z
z
z
z
Minimal distractions – eyes closed and
quiet surroundings
Muscles relaxed and comfortable posture
M t l focusing
Mental
f
i
- breathing
- repetition of a word
- image
Passive disregard of everyday thoughts
Practicing the Relaxation Response
z
z
z
z
Ten to twenty
minutes a day; time
is flexible
Quiet place and
comfortable posture
Any mental focus
that works is fine
It does not work for
a few individuals
Implementing treatment for
insomnia in Primary Care
z
z
z
Use sleep diary
Multiple approaches can be effective:
– Standard CBT 20-50 min in 4-6 sessions
– Abbreviated
Abb
i t d CBT (25 min
i session
i x 2)
– Phone, internet, self-help programs
Say Goodnight to Insomnia, Gregg Jacobs PhD
– Can be delivered by PCP, RN, counselor
ICD 9 code: 780.52 intrinsic sleep disorder NOS
(medical diagnosis)
Five Essential Ingredients for Sleep
Stable circadian rhythm –
temperature and light variation
z Exercise – mental and physical
z Sleep efficiency
z Positive sleep thoughts
z Ability to relax
z
NONPHARMACOLOGIC TREATMENT OF INSOMNIA IN PRIMARY CARE:
REFERENCES
General reviews:
Chesson AL Jr, Anderson JM, Littmer M et al. Practice parameters for the nonpharmacologic
treatment of chronic insomnia: an American Academy of Sleep Medicine report: Standards of
Practice Committee of the American Academy of Sleep Medicine. Sleep 1999;22:1128-33.
Sateia MJ, Nowell PD. Insomnia. Lancet 2004;364:1959-73.
Silber MH. Chronic insomnia. New Engl J Med 2005;353:803-10.
Cognitive-behavioral therapy
Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy.
Sleep 2003;26:177-82.
Jacobs GD, Pace-Schott EF< stickgold R et al. Cognitive behavior therapy and pharmacotherapy
for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med
2004;164:1888-96.
Sivertsen B, Omvik S, Palleson S et al. Cognitive behavioral therapy vs zopiclone for treatment
of chronic primary insomnia in older adults. JAMA 2006;295:2851-8.
Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior
therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.
Patient resources
Jacob GD. Say Goodnight to Insomnia. New York: Holt and Company, 1998.
Easy-to-follow 6 week self-help program
A Good Night’s Sleep. Age Page, National Institute on Aging
http://www.niapublications.org/agepages/sleep.asp
Basic information for older patients
National Sleep Foundation patient resources (Sleep Topics A to Zzz)
www.sleepfoundation.org
Commercially sponsored foundation with excellent patient education materials, including:
“Sleep Tips” and “Helping Yourself to a Good Night’s Sleep” – (environmental and lifestyle
factors)
“CBT for Insomnia: The Medicine-Free Approach to Treating Insomnia”
“Strategies for Shift Workers”
Last night,
when did
you go to
bed?
How long did How many
it take to fall
times did
asleep?
you awaken
during the
night?
Adapted from Jacobs, GD. Say Goodnight to Insomnia.
DATE
#1
#2
#3
#1
#2
#3
#1
#2
#3
#1
#2
#3
#1
#2
#3
#1
#2
#3
#1
#2
#3
How long
were you
awake each
time?
What was
your final
wake-up
time?
1 minute sleep diary
When did
you get out
of bed?
How many
hours from
“lights out”
to “out of
bed”?
About
how many
hours did
you sleep?