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A. unique, innovative with t of the nicest features ab downtown Denver in genera If you look at where cour to the Pepsi center. It w friendly. We had one of t bike share systems, bicyc get on one, you can use i really is downtown. You h dance clubs to places wit like the view house and n like the tavern. Denver's those like chef driven, o that you really could pic or 30. We have about 92 b at falling rock. If you'r beer, Denver is definitel the United States. Stoic in Denver Union Station. inside the station itself transformation of that hi they really took care to of what it looked like as So all light rail buses a be coming out of there. I to D. I. A. Which takes y of the great places downt hotels. One is the brown hotel. Also in our neighb cover, which is one of th stores. Just have that li feel when you walk in. Ju have here that makes dowt There's really a lot of a to Larimer Square gives y like Rockefeller Center m the only historic block t buildings. Larimer Square little boutiques that I t unique gifts. I always ta ranch where they're attrib the snap front western sh to ranchers. It's people something quintessentiall had one word for downtown active, historic, but eme artsy. It's kind of the h also a melting pot of our So if you're coming down a real sense of Denver, i Welcome to a C. P. M. I'm you're joining us today. I'm a share of the member my pleasure to be moderat we have title building pr considerations in bridging the evidence, recommendat The main goal of this ses different aspects about w don't have a guideline wh due to the resources at e evidence is mixed based o we're applying what we're my pleasure to introduce for today is Dr David Nev officer in the Center for improvement in the agency and quality. He is respon the dissemination of pati research and basically wh care delivery and catalyz across health care settin in the American Academy o and American College of P as an adjunct professor i Medicine and Biostatistics at the Unifor services, U Thank you, Dr. Pizan. I'll see if I can handle this technology. Yeah, so my name is David Niebuhr. I'm pleased to be part of a writing committee looking at a ACPM position statement on adverse childhood experiences screening. Dr. Kevin Sharon was the nominator for this topic and our writing team included Dr. Chandra Sikar and Dr. Wendt. So we have no disclosures and the views are our own and not our affiliated institutions. So by way of background, this work was done by the ACPM Science and Translation Committee. And just to orient you folks to this committee very briefly, the Science and Translation Committee or SNTC is charged with providing evidence-based guidance for the various forms of preventive medicine practice. It includes clinical, community and population, policy and advocacy recommendations. And the SNTC has developed a working group on adverse childhood events to draft an ACPM position statement for review and ultimate approval by the ACPM leadership. Our plan then is to follow this approved position statement with a submission to American Journal of Preventive Medicine for peer review and hopefully publication followed by a dissemination effort to members of the college and the public health community at large. The ultimate goal of our work is to reduce the lifelong morbidity and burden of chronic diseases associated with adverse childhood events. So in response then we review the evidence for ACE screening. So first by way of background, let me go over the ACE screening domains and instrument variables. So there's three types of ACEs included in the standard questionnaire. They include abuse, neglect, and household dysfunction. In the area of abuse there's physical, emotional and sexual. In terms of neglect there's physical and emotional. In terms of household dysfunction includes mental illness, trauma, substance abuse, incarceration. Now there's a couple of variations on the ACE. For children and adolescents the Bay Area Research Consortium on Toxic Stress and Health Center for Youth Wellness developed the PEARLS, which is the Pediatric ACEs and Related Life Events Screener. It adds to ACEs questions on toxic stress and these include things like economic hardship, community violence, and I'm sorry, and community violence. For adults the ACE questionnaire developed initially by Kaiser Permanente and used by the CDC principally within the BRFSS. So in terms of prevalence of ACE, this is 2011 to 2014 BRFSS data. You can see that only 38% of the population surveyed had no adverse childhood events in this time period and approximately 25% of the population had three or more adverse childhood events self-reported. How did that prevalence break out by gender? It was pretty similar for most of the categories with the exception of sexual abuse, which was much higher in women than in men, and incarcerated household members, which was higher in men than women. So ACE has been correlated consistently with chronic diseases and a number of outcomes, specifically behavioral, physical, and mental health. And you can see things like lack of physical activity, smoking, drug use, missed work for behavioral type outcomes, and severe diabetes, obesity, suicidal attempts, COPD, stroke, cancer, and heart disease. The literature has also consistently shown in correlation studies a dose response with the risk increasing as a number of ACEs increases. And ACEs have been implicated in five of the top 10 causes of U.S. mortality, specifically heart disease, lung disease, diabetes, cancer, and suicide. So let me talk a little bit about the methods that we use to develop this physician statement. So we developed three key questions related to ACEs. First, can ACEs be prevented? Second, is screening for ACEs effective? And finally, are interventions for elevated ACEs effective and associated with ARMS? In the interest of time today, I'm just going to present the second key question, is screening for ACEs effective? We performed a limited systematic review of systematic reviews. These are the database sources that we used to identify published systematic reviews. We then assessed the quality of each of the systematic reviews that met our inclusion criteria. Then we assessed the strength of evidence from the reviews. And we found a total of nine systematic reviews that partially covered the three key questions, and three of those were related specifically to ACE screening. Once we had reviewed those systematic reviews, we then surveyed ACE position statements of governmental agencies and professional and health organizations and looked at the evidence for each. And then we developed ACPM draft position statements by a consensus development process. And for each of the ACPM position statements, we assessed the strength of evidence. Then the position statement, the draft position statements were reviewed by an ACE subject matter expert who is published in the field, as well as the full ACPM Science and Translation Committee, and finally by the ACPM Executive Committee. So what were the results? So in terms of systematic reviews identified for ACE screening, we found three studies. You can see when and where they were published. They included a variety of study designs, including prior systematic reviews, cohort studies, case control studies, and a few RCTs. We're reporting over 67,000 subjects, but more than likely there is some duplication in that, so take that with a grain of salt, and approximately 153 studies. Our overall assessment of each of the systematic reviews in terms of quality was critically low. And if you're interested, that was performed in duplicate by using the assessment tool for assessment of systematic reviews or AMSTAR II. Okay, turning to other professional organizations' position statements on ACE screening. So the American Academy of Pediatrics in 2007 issued a statement based on expert opinion that ACE screening using a standardized schedule to identify risk factors that are highly prevalent or relevant to that particular practice setting should be considered. The American Heart Association in 2019 published a limited quality recommendation for universal screening in clinical practice and school settings where evidence-based treatment resources were available. And ASTHO in 2019 published a statement based on expert opinion that utilizes a population health approach that implements cross-sector partners to encourage the social and emotional well-being. CDC in 2019 had a good quality statement stating that surveillance data to help researchers, practitioners track changes in the ACE burden and the consequences at both the local, state, and federal levels should be implemented. The task force in 2018 made a good quality recommendation that there was inadequate evidence that interventions in primary care can prevent maltreatment among children who do not have signs and symptoms of maltreatment. Note that that was not specifically focused on ACE screening. The American Academy of Family Physicians in 2019 had an expert opinion statement saying screening should be done in the context of therapeutic relationships and shared decision-making. And finally, SAMHSA in 2014 published a statement with good quality evidence that practitioners should use the best available empirical evidence and science that are culturally appropriate and reflect principles of trauma-informed care. So, on to our recommendations. The S&T, the Science and Translation Committee, recommends that population-based surveillance and research with ACEs, along with lifestyle, behavioral factors, and social determinants of health, such as the CDC's BRFSS survey, is recommended. But ACEs, in our opinion, should not be used at this time for screening to include primary prevention, clinical assessment, or targeted interventions. And the reason for that is based on a limited quality patient-oriented evidence for effectiveness of these interventions and also because the potential for harms from administering ACEs in a, for example, primary prevention setting has been understudied. Furthermore, the Science and Translation Committee recommends that primary care providers and health systems should consider screening for adversity, trauma, and positive childhood, positive childhood events to include family relationships. A quote that we saw in the literature, which is very convincing, is that people are more than the sum of their adverse child events. So, it's important, the literature would suggest it's important not only to screen for adverse child events, but also for positive child events to get a full picture of a person's resilience. Screening for secondary prevention should be done in the context of therapeutic relationships and shared decision-making. And there are a number of prerequisite health system developments that are required, in our opinion, for ACE screening. And these include food and housing security, family protective factors, access to behavioral health care and safety protocols for suicidality and domestic violence. So, we also develop position statements on training and education related to ACE, policy, practice, and research, but we're not going to cover those today in this talk. We did recommend research through longitudinal intervention studies, real-world evidence, quasi-experimental, and pragmatic trials, recognizing the difficulty of doing RCTs, for example, in this field. And future research is needed to identify strategies that would optimize ACE screening and design appropriate interventions. For example, validation of the ACE screening in minority populations is sorely needed. Next steps include submitting a position statement to AGPM for peer review, followed by developing ACPM ACE dissemination products. And I'm out of time, so this is our conclusion, and I will pass it off. Thank you very much. Thank you, Dr. Niebuhr. Certainly, I have so many questions, and I bet our audience, too. Remember, put your questions in the chat. We'll have plenty of time for questions. Now, it's my pleasure to introduce Dr. Wilnice Jasmin. She's the Medical Director of Behavioral Health at the Chicago Department of Public Health. Her office leads the city's initiatives in the areas of violence, prevention, substance abuse, and prevention, and mental health. She specializes in preventive medicine and family medicine, and completed her preventive medicine training at the John Hopkins Bloomberg School of Public Health, and her family medicine residency at the Cook County Loyola Family Medicine Program. She was chief resident during her final year of family medicine, and we are so glad to have her here sharing just today her experience. And she is, I would like also to mention, she has been part of ACPN multiple committees since 2013, and we are so grateful to have her join us in this binary session. Dr. Jasmin, take it away. Thank you, Dr. Pinzon. Again, good afternoon. My name is Wilnice Jasmin, and I'm here to speak to you about the public health approach to the opioid epidemic. During this talk, whether you are already familiar with the story across our country when it comes to opioids, or whether this is not an area you've ever worked in, for the learning objectives, it's easy to cover a few buckets. So I'm going to speak broadly about the topic of opioid use disorder, review the current treatment options available, and how opioid use disorder can co-occur with mental illness, how the opioid epidemic has increased during this past year with the evolution of the COVID-19 pandemic, and then finally, how different interventions can fit into a public health practice paradigm. Before I get started, you should know that I am the principal investigator for my institution's Overdose Data to Action Cooperative Agreement grant from the CDC. And I also added the disclaimer you see here. So now let's jump right in. Whether you work in this field or not, I'm sure you are all at least aware that the country is experiencing an opioid epidemic or opioid crisis. According to the 2019 National Survey on Drug Use and Health, 10.1 million people misuse opioids. The American Society of Addiction Medicine, or ASAM, they define addictions as primary chronic relapsing disease of the brain, reward, motivation, memory, and related circuitry. Dysfunctions of these circuits, they lead to characteristic biological, psychological, social, and spiritual manifestations. And this is reflected in the individual pathology pursuing reward or relief by using their substance of choice, and in this case, it's opioids. You can see from the graph from the Kaiser Family Foundation that there has been a steady increase in the opioid overdose deaths since 1991, 1999, excuse me, with a steep increase beginning around 2014. These two graphs, they show age-adjusted deaths and the deaths by sex. This shows the death rate and number of deaths by race, both of them. The overall jump around 2014 holds true across racial groups. I know this is a public health talk, and we usually are concerned with the larger systems view of a problem. Very quickly, let's take a look at the actions of opioids on the cellular level. Once an opioid binds to the opioid receptor of a cell, many actions begin to take place. The calcium channels close and the camp levels decrease inside the cell. The calcium-sensitive potassium channels then open, leading to the hyperpolarization of the cell, and this results in the decreased transmission of pain. So that's one action of opioids, the decreased transmission of pain or analgesia. This picture depicts the cellular mechanism responsible for another effect of opioids in the system, the cardiac high sensation. On the cellular level, the opioid binds and stimulates the immune receptor in the ventral tegmental area of the brain, and it prevents the release of neurotransmitter GABA. GABA has an inhibitory action, and its absence leads to the release of dopamine into the nucleus accumbens, which then gives rise to feelings of pleasure or the experience of being high. Now for some terms. Abuse is no longer used in medical description. We now replace that term with use disorder. So the term opioid use disorder is highlighted here. We no longer use the term opioid abuse. The same holds true for other substance use disorders. The same holds true for other substances, like cocaine. We don't say cocaine abuse, but cocaine use disorder. Or more generally, substance abuse is no longer the standard descriptor. We say substance use disorder. Misuse, it can be used when describing the use of illegal drugs and the use of prescription drugs in a manner that is of them directed by the person prescribing the medication. Could be using in greater amounts or more often, or longer than what was instructed when the medication was prescribed. Here addiction, there's a more succinct description written here when I previously explained the ASAM definition of addiction. In general, addiction is a problematic pattern of use that harms with consequences. Whether the consequence is you are physically or psychologically affected in your health, or it leaves you unable to fulfill your normal obligations in life. Pseudo addiction here is last. It results from withholding opioids for pain that can be diagnosed, prevented, or treated with more aggressive opioid treatment. So as an aside, when I'm here in Chicago, and the opioid epidemic is mainly driven by illicit heroin and illicitly manufactured heroin products. So I'm sure other local jurisdictions, that may be true. It's important to know your local picture. Overall, however, on a more national point of view, the opioid epidemic is driven by prescription pill use. And there is some overlap between the two drivers that you may see someone whose addiction was triggered by prescription opioids, and then their supply was decreased. And then the person then turns to illicit forms such as heroin to compensate for that decreased supply. This has made many more prescribers more cautious in how much opioids are dispensed. And for certain populations, this results in the undertreatment of pain. And so the term pseudo addiction kicks in because the individual is asking for more medication, not because they have an increased tolerance or because they've become addicted, but because their pain is still interfering with their daily activities in their current low dose regimen. Here, I just explained at the beginning of the previous depicted here, the majority of the 10.1 million people in the nation who misuse opioids are misusing opioid pain relievers. And a smaller subset of people are using heroin or a combination of pain relievers and illicit opioids. The picture here shows the different areas of body affected by opioids. I spoke earlier about the effects in the brain and similar pain relieving effects occur in the spinal cord and peripheral nerves. And the brainstem is where our respiratory center is located. And opioids have an effect of decreasing our respiratory drive. And this decreased respiratory drive is what causes, most likely is the cause of death for individuals experiencing an overdose of opioids. In the tract, binding of the opioid receptors in the cells in the GI tract, it inhibits peristalsis, and this results in constipation. Here, the epidemic of opioid-related deaths is often described as the occurrence of three separate waves with three different drivers. The first wave is being mainly driven by opioids that are prescribed. The second wave, mainly driven by increased use in heroin. And then this latest third wave, being driven by synthetic opioids, such as fentanyl or fentanyl analogs, or other synthetic opioids. The latest one is isotonitizine. And then on the, you see there's a fourth wave depicted here. Could be actually due to polysubstance overdoses, or maybe the overdoses of substances adulterated with synthetic opioids. This fourth wave is yet to be seen, or we may actually be in the beginning of that fourth wave. Here, before, I alluded to the concept of the opioid pendulum throughout the talk, where treating pain, having a patient rate their pain, that led to the expectation of achieving a score of zero for pain as something that was possible. And that contributed to the judicious prescription of opioids. This led to an increase in opioid addiction that garnered the attention of public health experts and physicians nationwide. And it led to the implementing of policies and recommendations to restrict the use of opioids. What is safest for the patient? Is it limiting prescriptions for three to five days? Is it co-prescribing with an opioid antagonist to respond to overdoses? Or is it using a multiple of pain relief modalities other than opioids, or in conjunction with lower dose of opioids? That's the question we still face today. Here, it shows that there are three medications currently FDA approved to treat opioid use disorder. And up until late April, to prescribe these medications, physicians, nurse practitioners, and physician assistants and other prescribing clinicians, they would need to receive an X waiver training in order to prescribe these medications. These are controlled substances and require a DEA license to prescribe. And when a person received the training, the X waiver training, the DEA license would have an X designation, which that X is signified that the clinician could prescribe these medications. And the meds used for recovery from opioid addiction. The DEA, they no longer require the certification process and related to training and counseling to prescribe buprenorphine for opioid use disorder. This removal of the restriction, it only applies for treating up to 30 patients at one time. So organizations, they're still required to submit an application to designate it as a notice of intent in order to prescribe buprenorphine for opioid use disorder. But that training requirement is no longer there. Removing these two requirements, they'll decrease barriers to prescribing buprenorphine for opioid use disorder. I included this slide to highlight that opioid use disorder does not exist in a vacuum. And many people with opioid use disorder, they first turn to drugs to numb the pain of depression, anxiety, or other emotional trauma. And untreated mental health disorders, they may exacerbate addiction issues. And addiction issues may exacerbate mental health disorders. People with co-occurring substance use disorder and mental health illness may have different patterns of treatment. And they likely have complex treatment needs. The silo treatment approach is one that we should move away from and think of other considerations. And then speaking of silos, the opioid epidemic does not exist in a vacuum. And over the past year, we've seen that opioid use disorder there's no exception to the COVID-19's ability to exacerbate what was already an alarming trend. The CDC reported that multiple areas of the country were experiencing worsening, with some jurisdictions experiencing over a 50% increase in overdose deaths. And of the evidence-based to save lives is to ensure that naloxone is distributed widely. The medication is a opioid antagonist and it's used to reverse opioid overdoses when they occur. It can be delivered through three different routes, either through IM with using a syringe, IM using an auto-injector, or through the nasal route with a nasal spray. Of note, about two weeks ago, the FDA approved a new eight milligram formulation for the nasal spray. It's not available yet, but they anticipate it being available by the fall. And then the Association of State and Territorial Health Officials developed this framework for public health approaches to preventing substance misuse and addictions. And it incorporates the base interventions into primary, secondary, and tertiary prevention. And then I'm going to move on to the next slide. Prevention. And then I'll use the time during the panel to talk specifically about some of these interventions that are in the base. Thank you. Thank you so much, Dr. Jasmine. We are excited to hear more about those things. Now it's my pleasure to introduce Dr. Kapkan Huntersmead. He is currently the Chief of Preventive Medicine for the U.S. Army Medical Research Directorate in Africa. And he's joining us right now from Kenya. In this capacity, he performs research and disease surveillance on a variety of tropical diseases. He also serves as a subject matter expert for the Department of Defense Medical Ethics Center, and as an adjunct assistant professor for the Uniformed Service University in the Department of Preventive Medicine and Biostatistics. He has received several awards, including the ACPM's Donald Ginson Resident Award, and the U.S. Public Health Service Excellence in Public Health. Captain Smith completed his residency in the Uniformed Service University, and he's also been an amazing member of ACPN, serving in multiple of our committees, and we are so happy to have him. Take it away, Dr. Smith. All right, thank you so much, Dr. Pinzon. So, I'm gonna be talking about childhood obesity ethics, and kind of exploring those gaps in evidence that we have related to specifically the USPSTF recommendations. I'll talk a little bit about CPSTF as well, and also in their implementation. So, as always, here's our disclaimer statement, saying that what I say doesn't represent the government at all. And so, to set the stage, just a little bit of context for childhood obesity. Similar to those graphs that we saw for the opioid epidemic, we've been seeing similar upward trends, but over a much longer period for childhood obesity. As you can see, since the 1960s, it's really been increasing year over year, and up until our most recent data that we have from the 2018 NHANES, which showed that we have around 19% of US children and adolescents, ages two to 19, who have obesity, including 6.1% of those who have severe obesity, and another 16.1% on top of that, with overweight. And just quickly to note that childhood obesity and overweight is measured a little bit differently than adult overweight and obesity, in terms of the BMI. For children, it's based on the same kilograms per meter squared. However, it's age and sex specific as well. So, such that childhood obesity is defined as greater than the 95th percentile for BMI, which is a little bit different for adults. So, first off, childhood obesity has important health implications, both in the short-term and in its long-term consequences. About 80% of adolescents with obesity will inevitably have obesity as adults, and 65% of those who are pre-adolescent children with obesity will have obesity as adults. And just to illustrate that fact further, children with obesity are five times as likely as their peers to have obesity as adults if they did not have obesity as children growing up. And as we know, obesity in adulthood is associated with increased risk of a multitude of significant diseases, including cancers, cardiovascular disease, musculoskeletal conditions, mental health, across the board. And we see several of those in childhood as well, in terms of musculoskeletal, mental health, and a variety of other conditions as well. So, first off, the Community Preventive Services Task Force recommendations, what is the evidence for childhood obesity? So, the way that CPSCF kind of delineates its evidence for the interventions it recommends is between strong evidence and sufficient evidence. And as we can see here, there's really only one intervention for childhood obesity that they've found with strong evidence, and that's behavioral interventions that aim to reduce recreational sedentary screen time among children. And then there are four others with sufficient evidence. And all of these interventions found modest but meaningful decreases in BMI, or overweight and obesity prevalence, and were most updated fairly recently as of 2018 or 19. So, because for example, the USPSTF recommendation on childhood obesity in 2017 referenced that CPSTF found no interventions in schools that had sufficient evidence to recommend it. So, that's evolved over time as we've gained more data and more evidence to support these interventions. Okay, let me see here. Okay. And so, for the USPSTF, and this is what I'm really going to focus on today here. In 2017, they updated their recommendation from their 2010, which they had a B recommendation concluding with moderate certainty that the net benefit for children and adolescents six and older for screening for childhood obesity and then supplementary offering and referring them to comprehensive intensive behavioral interventions to promote improvements in weight status was moderate. So, moderate evidence for a moderate benefit. And overall, they found that these interventions with a total of at least 26 contact hours over a two to 12 month period resulted in some weight loss with a mean change in the BMI-Z score of 0.1 to 0.6. Though there's also a range in the adherence to these interventions ranging from 65 to 95%, which is a point I'll harp on a bit later in this talk. But that these effective greater than 26 hour contact hour interventions consisted of multiple components and varied pretty significantly across the different studies which often required these multidisciplinary teams, including pediatricians, physical therapists, dieticians, psychologists, to really encompass this comprehensive approach. But they also found these uncertainties in research gaps that were pretty important. First of all, is there a long-term benefit to these interventions? They found that up to a year after the interventions that the weight loss was maintained, but who knows for longer than that? And then also what constitutes clinically important health benefits and the amount of weight loss associated with those health benefits? Some evidence showed that the BMI-Z score decrease of 0.2 to 0.25 was clinically important. And so this would fall in that range, but other programs, maybe not so much. And so moving on to our next slide, or maybe not. Okay, there we go. So let's talk about the ethics. So the ethics of the gaps, the gaps in evidence. So first off is the research and development side of things. So there are many reasons to ensure diverse populations are included in biomedical research, because this is a major gap that we have for childhood obesity, is in these including diverse populations and these disadvantaged populations. And so an important way to ensure that USPSDF recommendations are applied equitably across populations is to first address these evidence gaps for vulnerable and disadvantaged populations. As part of its operations, USPSDF looks to implement the best evidence available for clinical preventive services across all populations. However, the data regarding diverse and vulnerable populations is often lacking. And further, these clinical and community intervention services are not equitably available across demographic groups. And this persistent gap in evidence and inequity in services, which perpetuate subjects like structural racism, are concerns that the USPSDF itself has called to be addressed both broadly and specifically for childhood obesity. And to illustrate the importance of this, when there is evidence that is relevant to specific populations, for example, variations in the epidemiology of the disease or the effectiveness of the preventive service, the USPSDF might issue separate grades for distinct populations by race, ethnicity, age, sex, et cetera. But not infrequently, there is a lack of robust evidence on subgroups which limits the USPSDF's ability to offer population-specific guidance. So if the USPSDF is to offer more nuanced recommendations for its clinical preventive services, it needs the evidence to be able to do so. And for childhood obesity, the USPSDF references this evidence gap and calls for more research to be conducted on diverse populations. And so, although the NIH, which is kind of that next step, uses these research needs and gaps raised by the USPSDF to guide their funding streams for future research, we're going to need further innovative solutions, integrated partnerships, long-term funding commitments to confront this complex issue. But it seems like they're making those next steps. And that's as evidenced by this UNITE initiative, which was recently created as of January of this year by the NIH, which is specific purposes to address structural racism in biomedical research. And for our next slide, sorry, it keeps losing connection here. Hmm. All right, there we go. So next, clinical implementation. So first, what makes for a good screening tool? First, you know, the Wilson and Youngner criteria are classically considered the standard reference for examining screening tools, though there are other screening criteria lists that have been developed over the years. But the core values of Wilson and Youngner remain applicable across most of these criteria lists. But one of these values states that there ought to be an accepted treatment for the disease being screened. However, as I discussed earlier, if there is an accepted intervention with minimal or no access to that intervention, then there's a real concern about the consequences of screening for it then. And it further raises the questions concerning another core value of a good screening tool, namely that there should be facilities for treatment available to those who are screened positive for the condition in question. And so many communities lack the access to these comprehensive, intensive behavioral interventions for childhood obesity, which I remind you is greater than 26 contact hours over up to a year period. And this leads us to ask ourselves, should clinicians advise preventive interventions to their patients based upon a USPSCF recommendation if there is limited or no accessibility for the practice despite its proven effectiveness in positive risk benefit calculus? And then next, if the treatment for the disease is being screened for is inaccessible for its target population, what then? So this is where the difference between health equality and health equity comes into play. And I'm sure everyone has these two concepts clearly delineated at this point, so I won't hammer away too extensively on that. But in this context, equality exists when everyone is offered the same exact service. However, there are instances where different solutions may be necessary to resolve issues of disparity and simple equality is not enough. For example, the referral to intensive behavioral counseling to all children with obesity may occur in all clinics while the accessibility of the service differs by patient and by community. And so a physician who makes the recommendation or referral may be providing sufficient care when such resources are accessible, but the equality and referral may not be sufficient in an area where such services are largely inaccessible. So what happens when intervention services are systematically inaccessible for specific population subgroups? For example, by race, ethnicity, socioeconomic status, rural or urban, namely an exacerbation of health disparities. So if we consider justice and equity to be ethical public health imperatives, we need to make efforts to fill in these gaps and meet standards of care. Equitable distribution and accessibility of these interventions are essential values in addressing childhood obesity in an ethical manner. If certain demographic groups are found to be systematically and consistently without access to these interventions, then there's a heightened ethical imperative to provide access to them. And the stakes are elevated even more so when it's considering children and adolescents as vulnerable groups. And so looking at the common sense clinical advice versus the evidence basis, and I'm sorry, I'm gonna go a little bit over my time here. A comparable case to this USPSDF recommendation regarding childhood obesity is the previous 2016 grade B recommendation for screening adolescents for depression in which the previous recommendation said that screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment and appropriate follow-up. And so that was a significant shift from its 2009 recommendation, which stated that screening should only be performed if such adequate systems were accessible. So part of the reasoning behind this change was the acknowledgment that regardless of the optimal services being accessible, that there remains this inherent value and merit to diagnosing, offering counsel, and providing interventions in the primary care setting. And then the other driving factor for that was the additional evidence supportive of depression management in the primary care setting. But a similar case could be made for screening of childhood obesity. Regardless of the services available, notifying children and the parents that the child has a diagnosis of obesity, a condition with important health ramifications, and advising that they ought to pursue behavioral interventions might be valuable. However, it's still, there's little evidence to show that simply conveying this information will result in the behavioral change necessary. And then finally, there's this lack of urgency from many clinicians and parents to address the issue, where we have this data that public opinion polls showing that Americans generally see obesity as a serious public health problem at over 50% saying that, but only 15% saying that it was a major problem for their family. And there's this cognitive dissonance there, and that further, that physicians with obesity are less likely to refer patients with obesity for obesity interventions, or document the patient's obesity in their charting compared to other physicians without obesity. And so the USPSDF recommendation doesn't just say that primary care providers ought to screen for obesity, but also that when screened positive, those children should also be referred, or offered comprehensive intensive behavioral intervention program. And for many other screening tools for other conditions, there's this automatic and compulsory reflex of the clinician to refer patients for the appropriate next step intervention, even when the cost of that intervention might be high or access might be limited. So for example, if a patient screens positive for an FOBT or a pap smear, then they're immediately referred to that next stage of testing or intervention, whether it be colonoscopy, biopsy, colposcopy, what have you. And there seems to be a little bit of a disconnect there for childhood obesity. And onto the final piece here. So the public health implementation side of things. So after we've identified which preventive actions are effective and worthwhile through reliable organizations like the USPSDF, it's critical that we ensure that these recommendations are being implemented universally, and especially where they're most needed, so we don't exacerbate existing health disparities. And we'll undoubtedly need creative solutions such as collaborations with community programs, video links, telemedicine, what have you, to ensure that our limited resource areas can establish and bolster childhood obesity interventions, both at the individual, clinical, and community levels. And government and political support will also likely be necessary to ensure these solutions are attainable. And while these gaps are being addressed, screening for childhood obesity should absolutely still continue, and that clinicians should continue to place a greater emphasis on screening, documenting, and offering interventions and counseling as feasible to their pediatric populations regarding obesity. Because some communities might not be able to offer evidence-based interventions, either through comprehensive multidisciplinary interventions or CPSTF recommendations. However, they might be able to still bring attention to the issue, and subsequently engage in alternate options that are less resource-intensive, recognizing these possible gaps in the evidence for their effectiveness. So to round things out, ultimately, children deserve the right to an open future. And what I mean by that is one in which they, upon reaching adulthood, have the ability to decide how they would like to shape the long arc of their lives. And by not having screening and preventive intervention modalities for childhood obesity accessible equitably across populations, this creates and exacerbates disparities in health outcomes between groups. And obesity can incur a terrible toll on those in whom it afflicts, ranging from impaired mental health, restricted mobility, organ failure, et cetera. And these comorbid and associated conditions can then limit a person's ability to fully pursue their goals unencumbered. And this point is highlighted knowing that we have USPSTF recommended, in other words, evidence-based and effective screening and preventive interventions for this disease, but that these services remain inaccessible or limited for many of the populations who need it most. And so I'm sorry I went a bit over my time, but these are some references, and thank you for listening. Thank you so much, Captain Hunter-Smith. Well, we still have a good amount of time for questions, and this part is going to be moderated by one of our board members, newly elected board members, Dr. Joseph Iser, who will introduce himself. Dr. Iser. Thank you very much. I've been working in public health for about 40 years since I did my internship and residency at city and county hospitals, and then joined the US Public Health Service and retired after almost 24 and a half years of active duty service. Since then, I've run four health departments, two in California and two in Nevada. I retired about a year ago and have been on the board actually for a year, and so this is my first, I guess, elected term to the board. And I am a fellow in both the American College of Physicians and American College of Preventive Medicine. So there are some questions coming up, but the presentations brought up, I think, some interesting questions for me. Dr. Jasmine, with the COVID epidemic, how has this changed the way in which opioid use disorder is both identified and treated? And what brings this to mind is also that over the last year, a lot of my own interpersonal medical care, I go to the VA, has been through videoconference. So how do you do that? Yeah. Also when it comes to treating opioid use disorder, videoconferencing has been instrumental. During the opioid epidemic around when it first started, around March or April, the federal government loosened restrictions on the use of telehealth when it came to treating people with opioid use disorders. Prior to this loosening, to initiate treatment, the visit needed to occur in person, and as a result of this change, the initial visit can be done via telehealth. And so that improved. Pharmacies also, they were allowed to deliver medications via mail. And also the federal government was also helping to encourage the use of prescribing a longer term, so a longer number of days of medication, because sometimes people would need to come back every day to receive their medication. So like with methadone, that usually requires a daily visit, and encouraging people to have one week's worth of medication. Thank you very much. Dr. Niebuhr, I think your presentation brought up as many questions for me as it did maybe solutions. And I'm thinking, you know, a lot of us in preventive medicine do a dual role. We're both clinicians and we're public health specialists. Now my job has been mostly in governmental public health, and we've thought of ACEs as being sort of a developing bible, but you bring up a lot of issues. How would, let's say, a practicing pediatrician take what you have found, what ACPM is coming up with, and put it into practice? Thanks for that question, Dr. Iser. I don't know if we can go to a backup slide 22 in my presentation. There's a lot of criticism of ACEs in the literature. It was developed in about 1998, largely in a white population in the Pacific Northwest. The questions have been largely the same, and, you know, there's been some modifications locally, but not nationally. For example, community trauma, so racism, for example, is not included in the current ACE survey. Likewise, positive childhood events is not included in the current. So there are recommendations, I think, principally from SAMHSA on what trauma-informed care should look like. You know, it needs to be in the setting of, you know, shared decision-making and with available resources. So kind of like Dr. Smith's presentation, there's, you know, there's just a lot of ethical gaps in the use of ACE screening for, certainly for primary prevention. But nevertheless, there's good evidence for what SAMHSA calls and others in the literature are called trauma-informed care. So I think that the clinician, you know, could consider using the ACE, recognizing that, you know, the evidence for adverse effects of ACE are unknown, and therefore, their healthcare settings would need protocols, you know, for suicidality, for example, or domestic violence if they're uncovered. So, you know, principle of medicine is, you know, don't ask a question that you're not prepared to deal with the answer. And so ACEs is one of those things where the literature is inconclusive, but evolving. It's certainly probably here to stay, but hopefully evolving to include more domains, not just personal, but community-based, as well as positive childhood events. So I think the clinician should stay tuned in considering integrating ACE at the individual level in the context of trauma-informed care. Captain Smith, you talk about the disparities overall, and then you talk about the disparities in the recommendations for screening for childhood obesity and implementation of that. Do you have any recommendations on how screening for childhood obesity could be implemented equitably? Right. Yeah. So I think in terms of just screening for it, it seems to be pretty well-established across different clinics across the country. It's something that, you know, you have established in your childhood growth charts and everything like that. But for that second piece, that second component of the USPSTF recommendation, where it's that implementation of the comprehensive behavioral interventions, that's the piece that really needs to have greater emphasis placed on it. And so when you think about, for example, the Affordable Care Act, which really recognized the importance of USPSTF grade A and B recommendations, which require them all to be covered by insurance. But what it fails to do is not mandate that those services be accessible necessarily. And so that's that next step, which I think will be very difficult in certain areas more so than others, for example, like rural areas or difficult to access urban areas. And at an individual level, an individual clinician level, an individual patient level, it'll be difficult and very wildly from person to person, because bringing a child out maybe like one hour away to the closest comprehensive behavioral intervention area for 26 total contact hours over a year period might not be feasible at all if you have a single parent working full time or two full time working parents. And how do you obtain that sort of access? And so I think necessarily it's going to require a really complex combination of community partnerships, but also with clinics and clinicians, but also in terms of state and governmental support. Thank you. Here's a question, another question from the audience, and I find it an interesting one. As I described myself, I've pretty much always worked in governmental public health, but is there a unique role that preventive medicine physicians can play in creating the built environments that make nutrition locally available, comprehensive interventions, and exercise more feasible and accessible for kids and their families? And let me also describe my state. I live in Nevada. It's a huge state geographically. It's got Las Vegas, which is one of the most urbanized of areas in the country, yet even part of the county, which ranges from driving at highway speeds north for an hour and a half and south for two hours, is very rural and more than that really frontier. You get beyond my county until you get up to Reno or so, and it's desert and some agriculture. So there's a difference between what I could do as the director of the Southern Nevada Health District in Las Vegas and even in the rural parts of my county, and what I could do as I visited and tried to work with those other counties where there's no public transportation for the most part. So in my state, that's where I see the biggest divide is rural and urban populations. I suspect in most states that's still true, and I think you would agree with that. But what role can we as Preventive Medicine physicians play in trying to develop the built environment to be able to support that? That's for you, Dirk. Yeah, and I think that's one of my soapboxes is I think we have a really unique and powerful voice here in Preventive Medicine in that we not only can excel at that individual physician patient dyad level, but really in that focus for communities and populations and public health. And so I think a major emphasis for us has to be addressing those things like social determinants of health, which includes the built environment and accessibility for nutritious foods and safe neighborhoods, walkable pathways, these sort of things. And so I feel that many times we kind of undersell ourselves in terms of how impactful our voices can be. Obviously reaching out to not just like our state and federal level governments, but also local government level, which is often underutilized. And yeah, like you mentioned, Dr. Iser, working with the county departments of health as well. But yeah, a lot of that will have to do with us as Preventive Medicine physicians, not just engaging with our communities, but also trying to recruit our fellow physicians who might not consider themselves as public health engaged as we are. Even though ultimately in my eyes, every physician specialty has a role in public health and should be engaged at their community levels to address these more upstream issues, which ultimately concern their patients and their populations. Dr. Jasmine, again, this is an APC. A lot of us are clinicians and I certainly have seen patients, even though I've run health departments over the years and was a U.S. Public Health Service commissioned officer. So this is an interesting question kind of for me, what is the role of drug screening for patients and what kind of a history would you look for before you decided to do any drug screening? Well, drug screening can occur when, let's say you're treating a person for pain. Screening would be helpful to know if they are on any other kind of drug, whether it's another prescription medication or an illicit medication. For example, specifically with opioids, if the person already is using a benzodiazepine, that could be a deadly combination. And so, yes, it's always good to speak to the patient to ask about their history, but it's also safe to see through the use of labs and screens to make sure that that kind of drug is not in their system. Thanks. Thanks. Dr. Niebuhr, if there aren't good USPSTF recommendations, what is the role of ACPM and perhaps other professional societies in coming up with recommendations or options when either the evidence is poor from the USPSTF or nonexistent? Is there a role? Well, in the Science and Translation Committee, we've argued that there is a role, even in the setting in which the evidence is limited. If there is no evidence or if there is evidence countered to effectiveness, then I would think we would, as a college and as a committee, we would stay away from a position statement on it. But, you know, in terms of a screening, there's so much heterogeneity in the literature. But having said that, the number of studies, the preponderance of evidence was persuasive to our committee and to the executive committee of the college. So much of health care and clinical or population based lacks high quality evidence. That's just a reality that we are faced. And certain conditions like social determinants of health, adverse child events, trauma, you know, or I believe that we have a ethical obligation. I'm interested in what Dr. Smith thinks, but I think we have an ethical obligation to begin making recommendations. Obviously, no college position statement is good indefinitely. They need to be revisited as the science evolves. And, you know, one of the things that we do in our position statements is advocate for high quality research in the field to address research gaps. So that's a big part of our position statement. And we really took pains in our position statement to not go beyond the evidence. So not only did we look at published literature, but we also looked at other professional organizations, the burden of disease and the associated morbidity, mortality, recognizing that there's not a consensus yet on highly effective interventions and an absence of evidence on harms that could be caused by screening and need for the screening instrument to evolve. But having said that, I think that's probably true for most recommendations, and that's why the U.S. Permanent Services Task Force re-reviews their recommendations periodically. So I think the college would be no different than the U.S. Permanent Services Task Force for putting out recommendations, policy statements, being very careful to state the quality of the evidence and with a commitment to re-evaluate the position statement as the evidence evolves. Kevin Smith, you're involved in this as well. And by the way, that was the biggest adjustment I had to make when I retired from the service was no longer being called Captain Iser, but now either Joe or Dr. Iser. And I think of those two, I prefer Joe, but Captain Smith, please. Yeah, I agree, Dr. Niebuhr. So there's, the ACPM has written ethical pieces, ethical statement papers before actually, and for Dr. Jasmine, it was on the direction of opioid research and where it should go. And ACPM came out with a specific statement saying that there's this ethical need to address more upstream research endeavors and with a preventive focus, with that kind of ideal that prevention is this kind of, in many circumstances, has an ethical primacy over treatment. If you can prevent the harm from occurring in the first place, rather than fixing it after it's occurred, then you should try to focus on that prevention. But I think, yeah, the interesting question that stems from Dr. Niebuhr's statement saying that ACPM might have this ethical impetus to fill these recommendation gaps where they are and to provide some sort of guidance where the evidence might be lacking or murky and other organizations might just say it's insufficient. And so I think overall, it leads us to this question of what exactly should our role as ACPM as an organization be? How aggressive do we want to be? How expansive do we want our role to be? I know, you know, kind of expanding out from that, we have our Hill Day, which includes our involvement in policy and trying to get high-level public health goals accomplished but also as a professional organization, what should our role be for addressing those gaps? And I think Dr. Niebuhr is right in that we can provide that service. We just need to find the folks who are willing to help fill that gap, fulfilling the gaps. Either of you or Dr. Jasmine. Oh, Dr. Jasmine, I see you're speaking but you must be muted. Are you able to hear me now? Yes. Perfect. I just wanted to add to the recommendation to address more primary prevention for addiction. I just want to go back for the viewers to watch it later. My final slide depicted a pyramid that talked about the primary, secondary and tertiary prevention efforts that can be made. And so built environment was focused more in the primary prevention. And I also want to tie that with, right now the CDC also conducted a survey that showed that people were using as a coping mechanism for stress substances like alcohol and drugs. And so that primary prevention could be the promotion of mental wellness and also addressing ACEs as well. And, you know, I love primary, secondary and tertiary prevention. When I taught public health, I tried to teach those concepts to either clinical students who were taking my public health course or public health to be professionals. And I think that we don't remember that primary prevention helps to get seatbelts or almost primary prevention. If they automatically engage, they are. And so those are the kinds of things that really help to save lives without us even thinking about it. So thank you for bringing us back to that point. Dr. Pinzon, do you have any thoughts on this issue? Not well, a little bit deeper. Captain Smith mentioned that there's no, don't ask a question that you cannot address. Don't do something that you don't have the resources, but I guess that's one of the things that I would like to hear from the panelists. What when we discover that we don't have the resources need way into asking the question or when the resources that we have, we identify that are not enough. How do you, how would you recommend or audience that address those things? Is that, do we need to have a very clear understanding? Is that a limit of, okay, what's the minimum that I could offer or the maximum that I need to offer before considering doing any of the recommended screenings or treatments? I guess I'll go first. I think it really matters if you're talking about primary, secondary, tertiary prevention. I think the bar is certainly higher in primary prevention than it would be for secondary. So if I had as a family physician, if I was seeing a patient with depression, I would screen for opioid use disorder and suicidality, whether I had state-of-the-art behavioral health services available to me or not. And then it's my role in terms of a therapeutic relationship to advocate for that patient to the greatest degree possible and accessible. So research is conducted in quote-unquote ideal circumstances largely. We're moving now more into a real world research, but generally speaking, if we're dealing with a cohort study or a trial, certainly the generalizability of those findings is limited, right? And also I think clinicians and public health physicians have an obligation, have ethical obligations to promote the welfare of their patients. And unfortunately, as I said earlier, the highest quality of evidence does not exist. That in my opinion, though, that's not an excuse to do nothing. So that's why we made our recommendations very carefully and it was vetted by a lot of people. And also I would just say that trauma-informed care has a much stronger evidence base. That was not our primary scope on ACE screening when we went into the topic, but it was important that we include that in our position statement. So I don't know if I fully answered your question, but I think we have an ethical obligation to do the best we can with the available evidence to promote the health and wellness of our patients and our populations. Dr. Jasmine? Yes, working for a local health department, you have access to a lot of various forms of data regarding your local jurisdiction. So if you investigate, for example, with overdoses, you can track the locations where the most number of overdoses occur in an area. So maybe those areas could be places where you could pilot programs and that evidence to make your case more widespread. I really like that answer. Before I retired, we were working with the Metropolitan Police Department, which includes the Sheriff and the City of Las Vegas in trying to identify where we saw overdoses so that they would find those, give that information to us so that we could try to emphasize screening and care in those areas. And they're not always where the unsheltered population is. It could be in other areas as well. Captain Smith? Yeah, and I think it's an interesting ethical area that Dr. Pinzon brings up, which is these medical and public health decision-making under conditions of uncertainty, where you don't have that solid evidence foundation on which to stand your ground. So, yeah, I agree with Dr. Pinzon. Yeah, I agree with Dr. Niebert. There's these differing levels of kind of rigor of evidence that is required for each of these different types of interventions you want to address. And that ultimately, it comes down to what do we have available and what can we do with the... It's almost like a distributive justice question, not just not in terms of resources, but in terms of evidence. And what is the best and most reasonable recommendation we can give based on what we have available? Because a lot of times, you can't do nothing. You have to do something. And instead of leaving it up to each of the individual clinicians' whims, organizations like ACPM can help provide at least a little bit of a stopgap there or any of the other professional organizations. I think this is an interesting question. I really can't read all of it, but the question is what upcoming statements is ACPM preparing in addition to the ones that you all have been working on? Well, I can speak for the Science and Translation Committee. The Advocacy Committee also is very busy with statements as well for the college. But our committee, the next one on the chopping block is the Opioid Use Disorder. And it's under the leadership of Dr. Kat Livingston. I think we're close to a draft report, which will be then staffed by the entire committee, revised based on comments, and then sent to the executive committee. So that's the next one. As a committee, we've brainstormed and we've come up with close to a dozen topics. And we're currently, we've developed a matrix for a variety of characteristics, for example, morbidity and mortality and effectiveness of interventions and et cetera, et cetera, that we are trying to apply to these topics and to rank order for priority. And then ultimately we will forward that prioritization that we come up with to the executive committee for their input and prioritization. So there's certainly no shortage of topics. And amongst them are things like social determinants of health and pandemic preparedness. Captain Smith, do you have any others that you're working on? No, not currently. Okay. So hold on and let me try to scroll on this one. In the real world, do we have any idea of how many health systems or health plans offer or pay for a 26 contact hour intervention for pediatric obesity? And should we continue to medicalize health? That's yours, Captain Smith, I believe. Yeah, sorry, I missed the first part of the question. In the real world, do we have any idea of how many health systems actually will pay for the 26 hour intervention for pediatric obesity? Right, so as part of the Affordable Care Act, it is a grade B recommendation. So insurances have to cover it. It's just a matter of the accessibility of it, I think more so. I don't know of many health systems that will help pay for the necessary time off for the parents to transport the children to get to those appointments or for getting the transportation to do so and maybe getting the paid time off to do so as well. So there's, you know, there's these challenges in terms of cost, certainly, that aren't covered by ACA in which many health systems likely would not help in terms of covering the necessary requirements to be able to fulfill at least the time and resource requirements to be able to get to that point, to even do the interventions, even if they're not covered by ACA. Even if the interventions themselves may be covered. So that goes back to kind of our previous conversation about rural versus urban. And even in urban areas, there likely aren't enough providers to do that. And in rural areas, one of the counties I've worked routinely with that you have never heard of is called Esmeralda here in Nevada. They don't even have, they don't have any physicians or nurse practitioners in the county, no hospital. So I think when we look at this rural urban divide, that that really brings up stark disparities. I think that's probably true, Dr. Jasmine, with access to screening and interventions in opioid or other use disorders, am I correct? It's true. If you look at the distribution prior to a few weeks ago, before the data waiver removed, physicians who were able to prescribe medications used to treat opioid use disorder, they were not evenly distributed through the country. And then you might find certain areas where the only option would be methadone, or maybe the only option might be buprenorphine, but you wouldn't see a location where the patient can truly choose the best option for them. And so I think there's more disparity in terms of options when it comes to the rural areas, but hopefully telehealth can change that. And I can tell you that I see the major universities, there are now three medical schools in Nevada, two, one at UNLV, Las Vegas, one at UNR in Reno, and they're both trying to set up, as well as some of the healthcare systems, telehealth, telemedicine services. And I think the VA has been pretty good at trying to reach out to some of its rural populations as well. We have about four minutes left. So I'll take the prerogative and ask Dr. Niebuhr to give sort of a one minute summary of where you think we are and where we need to go, and then we'll go to Dr. Jasmine, Captain Smith, and Dr. Pinzon. Well, thank you, Dr. Joe. I think in terms of the adverse childhood event screen, it is certainly an evolving field. The actual instrument, as I mentioned, is old. It's in desperate need of being updated with additional domains that go beyond just the individual. We as population health physicians know the importance of community level factors and all. And then the importance of looking at the whole person, whole person care. So really what we're looking at is not just adverse childhood events, but we're trying to measure resiliency, right? And so in order to move towards a screening tool for resiliency, I think in addition to community factors, one of the things I'd like to see in the field is moving towards inclusion of the positive childhood events as well. So it's certainly an evolving field. The instrument that we have right now is limited. For example, we don't know the frequency of harms with screening. That definitely needs to be studied at all. So I think as an ACPM position statement, we've made a measured recommendation based on the best available evidence, but like so many topics, we need to keep a close eye on the research in this field. Thank you. Has been 45 seconds. To address the opioid epidemic here, I think it will take the collaboration of multiple sectors. So not just public or perhaps expand the scope means when we say a public health, but also working with the criminal system when it comes to diverting people who do have, are found with opioids, working with based organizations to see if, to help support their outreach efforts, and then making sure that the medication is available and naloxone is available to reverse overdoses is to keep it because we know addiction also is relapsing and remitting. So we shouldn't put limits on the number of times someone may go in and out of recovery and just support them. Thank you. Captain Smith, maybe 30 seconds. All right. Go down to less than one minute. So, right. So for childhood obesity, I think it's multi-pronged as well, for particularly for the recommendations. One way is looking upstream in terms of the research that we're doing. The quality of our recommendations depend on the quality of our research that we perform and the diversity and inclusion that we include in that as well. Downstream more so the implementation of the childhood obesity recommendations and how we can best support that in a way that allows it to be equitably implemented. Dr. Pinzon, can I leave it to you to say the last few seconds and to, I think both of us thank the presenters and we thank the ACPM staff and the other staff who've made this possible. It's yours. Thank you everybody for being here. If you want to, if you have more questions or want to be part of this work that's happening at the ACPM, contact us. You can send us an email, send your business card to all the speakers. I know they will be happy to talk to you more about this offline. Have a good day. Thank you.

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