Substance Use Disorders and ASAM Patient...

Substance Use Disorders and ASAM Patient Placement Criteria

Rochelle Head-Dunham, MD, FAPA Medical Director/Chief of Adult Services DHH/Office for Behavioral Health

Objectives

1. Discuss defining criteria for Substance Use Disorders

2. Highlight General Principles of the Neurobiology of Addiction

3. Review the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria

SUBSTANCE USE DISORDERS

4

Terminology

• Dual-disorders vs Co-occurring Disorders • Use vs Misuse vs Abuse • Tolerance vs Physiological Dependence • Physiological Dependence vs Addiction • Pseudo-addiction • Assessment vs Patient Placement Criteria

5

General Principles & Considerations

• Heterogeneity of the addiction populations

• Diagnosing with expectation not exception • Holistic evaluations and comprehensive

treatment planning • Unique person-centered and family

focused treatment approaches are required to enhance outcomes

• Significant predictors of treatment success are continuous, empathic relationships and coordination of care

6

Diagnostic Statistical Manual (DSM) Multi-Axial System

7

Axis I: Clinical Disorders (Mental Illness and Addictive Disorders) Other Conditions That may be a Focus of Clinical Attention Axis II: Personality Disorders; Developmental Disabilities Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems (“Stressors”) Axis V: Global Assessment of Functioning (GAF)

Interrelationship of Substance Use and Mental (Psychiatric) Disorders

Psychiatric disorders and substance use disorders can evolve independently through different, unrelated processes

Symptoms of psychiatric and substance use disorders can be expressed independently or simultaneously

Both disorders can mimic or mask symptoms of the other, i.e., cocaine intoxication can mimic schizophrenic; depression can mimic cocaine induced mood disorder.

A relapse of one disorder can precipitate acute symptoms of the other disorder.

Psychiatric symptoms may emerge with cessation of alcohol/drug use (i.e., first break schizophrenic).

Commonly Co-Occurring Mental Disorders (Axis I)

1. Mood Disorders are disorders that present with a disturbance in

mood as a predominant feature; Major Depressive Disorders, Bipolar Disorders, substance Induced Mood Disorders, commonly co-occur with addictive disorders

2. Anxiety Disorders are disorders that present with anxiety (fear) as

the predominant feature. Panic disorder, Social Anxiety Disorder, Generalized Anxiety Disorder, and Post-Traumatic Stress Disorder, commonly co-occur with addictive disorders.

3. Psychotic Disorders are disorders which typically present with

“psychosis” or gross impairment in reality testing evidenced by delusional thinking, disorganized speech, or disorganized/ catatonic behavior. Schizophrenia, Schizoaffective disorder, and Delusional disorder, co-occur with addictive disorders.

10

Personality Disorders Co-occur with Substance Use (Axis II)

A Personality Disorder is an enduring

pattern of inner experience and behavior that deviates markedly from the

expectations of the individual’s culture, is pervasive and inflexible, has an onset in

adolescence or early adulthood, is stable over

time, and leads to distress or impairment, and is

manifested in at least two of the following areas:

Cognition, Affectivity, Interpersonal functioning or Impulse Control.

DSM-IV TR

Medical Co-morbidity and Substance Use (Axis III)

12

Inhalant use among 12 – 17 year olds and depression are increasing;

Patients in chemical dependency programs are 18 times more likely to have major psychosis, 15 times more likely to have depression and 9 times more likely to have an anxiety disorder;

Substance use increases the risk for hypertension (x2), congestive heart failure (x9) and pneumonia (x12);

HIV patients with a substance use disorder are more likely to be non-adherent;

Medicaid patients with a substance use disorder are more likely to be readmitted to a hospital within 30 days;

Medical Co-morbidity and Substance Use (Axis III)

13

Substance use creates increased rates of complications with hip replacements;

Patients treated with medication for alcoholism had fewer detoxification, alcohol related inpatient days and emergency room visits;

High cost Medicaid recipients with HIV had an average annual cost of $157,000, with 40% higher costs for treatment of co-morbid MH/SU disorders , the most common co-morbidities

Treating patients with substance use related medical disorders in an integrated setting can achieve cost savings;

Definition of Substance Related Disorders

Substance Related Disorders are disorders resulting from ingestion of a drug of abuse (including alcohol), along with the development of the side effects of a medication, or from toxin exposure.” “Substance” can refer to a drug of abuse, a medication, or a toxin. Patterns of use have been researched for eleven substances: Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogens, Inhalants, Nicotine, Opioids, Phencyclidines and Sedative hypnotics/Benzodiazepines.

Diagnoses Associated With Classes Of Substances

Table 1. Diagnoses associated with class of substances Depen-

dence Abuse Intoxi-

cation With- drawal

Intoxi- cation Delirium

With- drawal Delirium

Dementia Amnestic Disorder

Psychotic Disorders

Mood Disorders

Anxiety Disorders

Sexual Dysfunc- tions

Sleep Disorders

Alcohol x x x x I W P P I/W I/W I/W I I/W Amphetamines x x x x I I I/W I I I/W Caffeine x I I Cannabis x x x I I I Cocaine x x x x I I I/W I/W I I/W Hallucinogens x x x I I I I Inhalants x x x I P I I I Nicotine x x Opioids x x x x I I I I I/W Phencyclidine x x x I I I I Sedatives, hypnotics, or anxiolytics

x

x x x I

W P P I/W I/W W I I/W

Polysubstance

x

Other x x x x I W P P I/W I/W I/W I I/W *Also Hallucinogen Perception Disorder (Flashbacks). Note: X, I, W, I/W, or P indicates that the category is recognized in DSM-IV. In addition, I indicates that the specifier With Onset During Intoxication may be noted for the category (except for Intoxication Delirium); W indicates that the specifier With Onset During Withdrawal may be noted for the category (except for Withdrawal Delirium); and I/W indicates that either With Onset During Intoxication or With Onset During Withdrawal may be noted for the category. P indicates that the disorder is Persisting.

Diagnoses Associated With Classes Of Substances (Illustrated)


dence Abuse Intoxi-

cation With- drawal




Psychotic Disorders

Mood Disorders

Anxiety Disorders


Sleep Disorders

Classes of Substances Alcohol

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Amphetamines

x

x

x

x

I

I

I/W

I

I

I/W

Caffeine

x

I I

Cannabis

x

x

x

I

I

I

Cocaine

x

x

x

x

I

I

I/W

I/W

I

I/W

Hallucinogens

x

x

x

I

I

I

I

Inhalants

x

x

x

I

P

I

I

I

Nicotine

x

x

Opioids

x

x

x

x

I

I

I

I

I/W

Phencyclidine

x

x

x

I

I

I

I

Sedatives, hypnotics, or anxiolytics

x

x

x

x

I

W

P

P

I/W

I/W

W

I

I/W

Polysubstance

x

Other

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Diagnostic Considerations DSM IV-TR

The Diagnostic and Statistical Manual (DSM-IV) has established two broad categories for the

distinction of Addictive Disorders: A. “Use Disorders” are those diagnostic states which

name the substance of abuse and assign severity (i.e., alcohol abuse or dependence…) or acuity (cocaine intoxication or withdrawal).

B. “Induced Disorders” are those diagnostic states which occur as a result of the psychological consequences of ingested chemicals (i.e.., cocaine induced psychosis, methamphetamine induced mood disorder…).

17

Diagnostic Determinants

• Diagnostic determinants of “Abuse” versus “Dependence”, “Withdrawal” versus “Intoxication” are drug pharmacology and behavioral patterns/consequences of use

• Rationale for appropriate placement decisions must take into consideration, all of the above as determinants of severity and acuity.

Diagnostic Determinants

“Use Disorders” Intoxication and Withdrawal

Diagnoses Associated With Classes Of Substances: Use Disorders (Illustrated)


dence Abuse Intoxi-

cation With- drawal




Psychotic Disorders

Mood Disorders

Anxiety Disorders


Sleep Disorders

USE DISORDERS Alcohol

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Amphetamines

x

x

x

x

I

I

I/W

I

I

I/W

Caffeine

x

I I

Cannabis

x

x

x

I

I

I

Cocaine

x

x

x

x

I

I

I/W

I/W

I

I/W

Hallucinogens

x

x

x

I

I

I

I

Inhalants

x

x

x

I

P

I

I

I

Nicotine

x

x

Opioids

x

x

x

x

I

I

I

I

I/W

Phencyclidine

x

x

x

I

I

I

I


x

x

x

x

I

W

P

P

I/W

I/W

W

I

I/W

Polysubstance

x

Other

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Diagnoses Associated With Classes Of Substances: Diagnostic Possibilities (Illustrated)

Diagnoses Associated With Classes Of Substances: Diagnostic Possibilities (Illustrated)


dence Abuse Intoxi-

cation With- drawal




Psychotic Disorders

Mood Disorders

Anxiety Disorders


Sleep Disorders

Alcohol

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Amphetamines

x

x

x

x

I

I

I/W

I

I

I/W

Caffeine

x

I I

Cannabis

x

x

x

I

I

I

Cocaine

x

x

x

x

I

I

I/W

I/W

I

I/W

Hallucinogens

x

x

x

I

I

I

I

Inhalants

x

x

x

I

P

I

I

I

Nicotine

x

x

Opioids

x

x

x

x

I

I

I

I

I/W

Phencyclidine

x

x

x

I

I

I

I


x

x

x

x

I

W

P

P

I/W

I/W

W

I

I/W

Polysubstance

x

Other

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Medication Options

“Induced Disorders”

Medication Considerations

Medications and Induced States • Drugs and Alcohol induce a complex array of

symptoms which are very similar to mental disorders in those who do not use drugs and alcohol.

• Use of psychotropic medications is therefore indicated to manage the psychiatric symptoms, independent of the cause for their expression. (Some cautions are necessary.)

24

Diagnoses Associated With Classes Of Substances: Induced Disorders (Illustrated)


dence Abuse Intoxi-

cation With- drawal




Psychotic Disorders

Mood Disorders

Anxiety Disorders


Sleep Disorders

INDUCED DISORDERS Alcohol

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

Amphetamines

x

x

x

x

I

I

I/W

I

I

I/W

Caffeine

x

I I

Cannabis

x

x

x

I

I

I

Cocaine

x

x

x

x

I

I

I/W

I/W

I

I/W

Hallucinogens

x

x

x

I

I

I

I

Inhalants

x

x

x

I

P

I

I

I

Nicotine

x

x

Opioids

x

x

x

x

I

I

I

I

I/W

Phencyclidine

x

x

x

I

I

I

I


x

x

x

x

I

W

P

P

I/W

I/W

W

I

I/W

Polysubstance

x

Other

x

x

x

x

I

W

P

P

I/W

I/W

I/W

I

I/W

DSM V Eliminates the Multi-Axial System

• Axis I, II, and III (all diagnosis) are combined • Axis IV Stressors are eliminated, replaced by

– ICD-9-CM V codes – ICD-10-CM Z codes after October 2014

• Axis V GAF is eliminated-new options are – World Health Organization Disability Assessment

Schedule (WHO-DAS 2.0)

26

DSM-V Diagnostic Considerations

• Substance-Related and Addictive Disorders • Substance Abuse and Substance Dependence now

consolidated into “Substance Use Disorder”, with severity continuum of mild, moderate, or severe

• Legal consequences criterion removed and craving criterion added to “Substance Use Disorder”

• Tolerance and Withdrawal criteria are not counted if the substance is prescribed by a physician

• “Gambling Disorder” has been moved from the Impulse-Control Disorders chapter in DSM-IV to this chapter in DSM-5

27

NEUROBIOLOGY OF ADDICTION

28

What is Addiction?

The repetitive compulsive use of anything in spite of adverse consequences and

ineffectiveness. This is regardless of the drug

or behavior used.

What are we Addicted to?

Below the level of the cortex the brain has a reward center. This center is necessary for us to learn what we should do again. It is a necessary survival mechanism. It can go awry and when it does we can be addicted. The main neurotransmitter active at this

site is DOPAMINE. Wetsman, 2007

The Dopamine Spike

Anatomy of the Reward System

Dopamine Spike

• Electrical stimulation of the MFB in humans

• Electrical self stimulation of the MFB in mammals

• Degree of reward varies with rate of rise • Craving starts on the way down • Everyone has enough at the peak

Wetsman, 2007

The Reward System

Non-selective and

Indiscriminant

Addiction Definitions

• Impaired control • Preoccupation with the drug • Use despite adverse consequences • Distortions in cognition (denial and others)

ASAM • Addiction can be defined as compulsive

drug seeking and drug taking, with a loss of control over drug use. APA

• Maladaptive pattern of use • Significant impairment or distress • Three or more of the following within any 12 month

period: DSMIV

35

Definitions DSMIV (cont’d)

Tolerance

Withdrawal

Broken limits

Persistent desire or unsuccessful efforts

Excessive time spent

Important activities given up

Use despite adverse consequences

36

Why Addiction, Not Dependence?

History of the term “Dependence” and the APA. WHO and physically vs psychologically

“addicting.” Addiction without physical dependence. Dependence without addiction. Dependence vs. Tolerance

Wetsman, 2007

So What About Abuse?

Addiction is a sick brain doing it’s best to feel better. Abuse is a healthy brain doing stupid

things with drugs. There is no evidence of one leading to

the other. You can have one or the other first and then develop the other one.

Wetsman, 2007

So What About Abuse

Abuse is to “won’t” -- as addiction is to “can’t”. Abuse is a normal brain needing no

medicines (other than for whatever else is wrong with it) and addiction is an ill brain that often needs medical help. Treatments for Abuse vs Dependence

are Different!

Wetsman, 2007

DSM IV-TR Abuse (Cont)

Key Point: THE SYMPTOMS HAVE NEVER MET

THE CRITERIA FOR SUBSTANCE DEPENDENCE FOR THIS CLASS OF

SUBSTANCE. Wetsman, 2007

American Society of Addiction Medicine -

Patient Placement Criteria (ASAM–PPC)

41

42

What is happening in some programs in America?

• Clients are being referred to the wrong levels of care.

• Clients are often referred to, and treated in the agency conducting the

assessment.

• Clinical Assessments do not justify the recommendations being made.

• Clinical Justifications are not required.

• If provided clinical justifications do not include clinical rationale / evidence supporting the recommendation.

• There are little to no policies or procedures that address the format and or quality of assessments, patient placement decisions, and clinical justifications

43

Why Do We Need to Improve Patient Placement and Clinical Justifications?

• Improved Performance and Treatment Outcomes

• Increase Initiation, Engagement & Retention Rates

• More Efficient & Effective Utilization of Resources

• Shift to Performance Based Contracting

• Positions Organizations for Medicaid and Private Insurance Reimbursement

44

Question

QUESTION: How does this lack of consistency interpreting clinical information impact treatment?

45

Treatment Implications

Answer: Client’s receive the Wrong……… 1. Diagnosis or Diagnostic Impression 2. Level of Care Recommendation 3. Services and Interventions

As a result, the client’s chances of being

successful in treatment are compromised right from the beginning of the treatment process.

46

Question

QUESTION: What Does Research Say About Mismatching Clients to Treatment?

Louisiana Department of Health and 47

Treatment Implications

ANSWER: Clients that are mismatched to treatment have lower retention rates and poorer outcomes. Less treatment is NOT Good. More treatment is NOT Good. One study found that No Treatment was better than the wrong treatment. (Knight, K., 2009)

48

• Uniform Patient Placement Criteria (e.g., ASAM, LOCUS …) describe in detail the levels of care along the continuum of care, and provide specific guidelines for Patient Placement Decisions, a.k.a., Level of Care recommendations.

General Components of UPPC Level of Care Continuum Dimensions of Assessment Criteria (e.g., admission, continued stay & discharge)

Uniform Patient Placement Criteria Defined

49

ASAM Dimensions

• ASAM Six (6)Dimensions: The client’s risk status in each of the six dimensions collectively inform the patient

placement decision.

1. Acute Intoxication and/or Withdrawal Potential.

2. Biomedical Conditions and Complications.

3. Emotional, Behavioral, or Cognitive Problems and Complications.

4. Readiness to Change.

5. Relapse, Continued Use, or Continued Problem Potential

6. Recovery Environment.

50

Benefits of UPPC • Uniform Patient Placement Criteria:

1. Guides proper patient placement.

2. Promotes individualized care.

3. Identifies critical information to be collected during an assessment.

4. Influences multidimensional treatment planning.

5. Establishes a common language.

6. Identifies gaps in a continuum of care.

51

IMPORTANT !!!

Criteria are NOT substitutes for GOOD Clinical Judgment.

Tools, and Criteria’s support, guide

and enhance GOOD Clinical Judgment!

ASAM PPC - 2R

ASAM Historical and Theoretical Foundations

The ASAM PPC – 2 is published by the American Society of Addiction Medicine. Used as a clinical guide in matching patients

to the correct level of care. Expands use of multidimensional assessments

in developing objective patient placement decisions at various levels of care. Emphasis on intensities of along a continuum,

in a variety of program types and levels of care

52

ASAM PPC - 2R

ASAM Historical and Theoretical Foundations

• The continuing development and refinement of the criteria continue a shift from:

Uni-dimensional to multidimensional assessment.

Program-driven to clinically driven treatment.

Fixed length of service to variable length of service.

A limited number of discrete levels of care to a continuum of care.

53

ASAM PPC - 2R

Theoretical Foundations of the ASAM PPC

• Goals of Treatment: Tailored to individuals needs (length, choice) Guided by individualized treatment plan. Client directed treatment plan. Based on comprehensive bio-psychosocial assessment

of person and when possible, family. Should list problems, strengths, priorities, goals,

methods or strategies. Safety first

54

ASAM Placement Considerations

• Placement decisions are determined based upon consideration of:

Level of Service/Care most appropriate to meet the clinical needs

Dimensional Assessments “Primary” and “Secondary “ Determinants

Louisiana Department of Health and Hospitals 55

ASAM PPC - 2R

Exceptions to PPC There are 3 exceptions which override the PPC match: Lack of the availability of the appropriate selected care.

Failure of a patient to progress at a given level of care so

as to warrant a reassessment of the treatment plan with a view to modification of the treatment approach.

State laws regulating requiring different criteria.

56

ASAM PPC - 2R

ASAM Levels of Service

• Levels of Care: Level 0.5 Early Intervention Level I Outpatient Treatment Level II Intensive Outpatient / Partial Hospitalization Level III Residential/Inpatient Treatment Level IV Medically Managed Intensive Hospital/Inpatient Treatment

• (Note: .1 to .9 represents graduated intensity within an existing level of care.)

57

Levels of Care ASAM PPC - 2R

Levels 0.5 Early Intervention

“Prevention Focus”

Individuals at risk for developing substance-related

problems or

Those without sufficient information to document a

substance use disorder.

Staffing (Essential)

Licensed Prevention

Professionals

Partnerships

Department of Education


Levels I

Outpatient Care (<9hrs/week Adults <6hrs/week Adols)

Organized services delivered in a wide variety of outpatient settings.

Prescriptive services, regularly scheduled sessions, a defined set of policies and

procedures or medical protocols.

Accommodates high severity D4, unmotivated mandated persons;

expanded for COD


MD, Nurse, Clinicians/

Counselors, Care

Coordinator, Peer Mentors

(strongly recommended)


Level II Intensive

Outpatient/Partial Hospitalization (>9hrs/wk)

Partial 9-20hrs/wk; IOP 20hrs/</wk

Organized, clinically intensive services delivered during the day, before or after

work/school, in the evening or on weekends.

Provides essential education and treatment components while allowing patients to apply their newly acquired skills within “real world”

environments.


MD, Nurse, Clinicians/

Counselors, Care

Coordinator, Peer Mentors

(strongly recommended


Level III Residential/Inpatient

Treatment

Organized, 24hr services, staffed by trained medical and counseling staff

to stabilize multidimensional problems, as prep for outpatient

treatment.

Defined set of policies and procedures foster reliance on the treatment

community as a therapeutic agents .

Designed to treat person who have significant social and

psychological problems

Housed in or affiliated with permanent residential facilities.

Generally provide access to on-site self-help meetings.


MD(s), Nurse(s),

Psych Techs Clinicians/

Counselors, Care

Coordinator

Staffing (Optional)

Psychologist, Occupational

Therapist, Peer

Mentors


Level III. 7D Residential

Medically Monitored/Supported Detox

Organized 24 hour nursing care and daily physician care

for severe, unstable problems in Dimensions 1, 2 or 3.

Counselors available.

Appropriate for patients whose

subacute biomedical, emotional, behavioral and cognitive problems are so severe that they require residential

care not a full service hospital.


MD(s) (AD Psych/Primary

Care w/ ASAM); APRN/NP/RN; Psych Techs; Clinicians/

Counselors, Care Coordinator,

Staffing (Optional)

Peer Mentor


Level IV.D Medically Managed Intensive Hospital/ Inpatient

Treatment

Organized 24 hour nursing care and daily physician care for

severe, unstable problems in Dimensions 1, 2 or 3. Counselors available.

Appropriate for patients whose acute biomedical, emotional, behavioral and cognitive problems are so severe that

they require primary medical and nursing care

Full resources of a general

acute care psychiatric hospital are available.


MD(s) (AD Psych/Primary

Care w/ ASAM); APRN/NP/RN; Psych Techs; Clinicians/

Counselors, Care Coordinator,

Staffing (Optional)

Peer Mentor


Opioid

Maintenance Therapy

Best conceptualized as a separate service that can be provided at any level of care but typically, Level I Outpatient

in an ambulatory setting.

Daily or several times weekly opioid medication and counseling available to maintain multidimensional stability for

those with opioid dependency.


MD, Nurse, Clinician or Counselor

Dimensional Criteria ASAM’s 6 assessment dimensions allow for

multidimensional considerations in the determination of best level of care placements.

Primary Determinants • Acute Detox • Medical Complications • Psychiatric Difficulties

Secondary Determinants • Change readiness • Relapse, continued use, continued

problem potential • Recovery/Living Environment

Summary

• Addiction populations are heterogeneous • Neurobiology of addiction supports a chronic,

relapsing condition and the disease concept • Diagnose with expectation not exception • Holistic evaluations and comprehensive

treatment planning with care coordination are critical

• Appropriate “dosing” of care is critical to successful outcomes

• Unique person-centered, family focused empathic treatment approaches are required to enhance outcomes

66


References • American Psychiatric Association, Diagnostic and Statistical manual of Mental

Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association, 2000.

• Carroll, K.M. Methodological issues and problems in the assessment of substance use. Psychological Assessment 7:349–358, 1995.

• Donovan, D.M., and Marlatt, G.A., eds. Assessment of Addictive Behaviors. New York: Guilford Press, 1988.

• McLellan, A.T.; Kushner, H.; Metzger, D.; Peters, R.; Smith, I.; Grissom, G.; Pettinati, H.; and Argeriou, M. The fifth edition of the Addiction Severity Index. J Substance Abuse Treat 9:199–213, 1992b.


References • Mee-Lee, D.; Shulman, G.D.; Fishman, M.; Gastfriend, D.R.; and Grifith, J.H. Patient Placement

Criteria for the Treatment of Substance-Related Disorders. 2d ed., rev. Chevy Chase, MD: American Society of Addiction Medicine, 2001.

• Meyers, A. Thomas McLellan, J. Jaeger, H. Pettinati ,The development of the comprehensive addiction severity index for adolescents (CASI-A) An interview for assessing multiple problems of adolescents. Journal of Substance Abuse Treatment, Volume 12, Issue 3, Pages 181-193 K.

• Spitzer, R.L., Williams, J.B.W., Gibbon, M. & First, M.B. Structured Clinical Interview for DSM- III-R-Patient Version. New York: New York State Psychiatric Institute, Biometrics Research Department, 1988.

• Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G.C. The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-1V and ICD-10. Journal of Clinical Psychiatry, 59 (suppl. 20), 1998.

Questions and Discussion

Rochelle Head-Dunham, MD

[email protected] 225.342.8916

69

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