Role of acute care prescribing in the opioid epidemic

>> So thanks, Dan. It’s a pleasure to
be here today. And I’m really impressed
by the attendance. You guys have been
here and engaged, and I’m very appreciative
of you attending today. I’m going to be talking about
opioids, and probably opioids in a way that you haven’t
classically heard of it. Some of you have heard
this lecture before and will see some repeat data, but we actually do have
new data all the time. I’ll be talking about
opioids as it relates to acute care prescribed, and
specifically surgery, dentistry, and emergency medicine. But I think no matter
what role you play in the healthcare system,
this should resonate, or just in your own
personal experiences. We have funding from NIDA, as
well as the Michigan Department of Health and Human Services. So this really is a
partnership between MDHHS, and Blue Cross/Blue
Shield of Michigan, and the University of Michigan. I have — I do consult
for Heron Therapeutics, but I won’t be discussing
their products today. So everybody’s aware
of the opioid epidemic. I started giving this lecture
about three or four years ago, and I would say 78 desks
per day, and then 91, and then 115 desks per day, and
now more than 130 desks per day. And just that number
always seemed to be enough. Just simply saying, “Seventy
eight desks per day a few years ago,” I thought that was enough. I could make the analogy of
planes falling out of the sky, but then as I’ve traveled
more and spoken more, I’d probably give one to two
opioid-related lectures a week, I’ve started to hear
more stories. And I’ll be blunt, these stories
stick with me in a very deep and personal way,
and they drive me. And I’ll tell you one story — and some of you have
heard this story because I’ve actually
had the pleasure — or I don’t know if I’d
really call it a pleasure, but I’ve been very
fortunate to have a colleague and a friend present with me. And it tells the story of a
son, grew up in a loving house, parents who loved him,
brother who loved him, handsome young man; very,
very good hockey player, and had a musculoskeletal
hockey injury. Didn’t have surgery but very
well could have had surgery. He was given opioids for
that musculoskeletal injury. And his brother now tells
years later that he knew in that moment he liked opioids. He really liked Oxycodone. And after he had gone
through his own supply, he started buying the supply
from their housecleaner, who was taking opioids
from other people’s homes and redistributing them. And his brother knew this,
but he was sworn to secrecy. His father thought
this was a teenaged son who was just being a jerk;
there are other words that he could use, right? Didn’t realize that this was
a sign of something deeper and his son eventually
moved to heroin. And as he moved down this
path of heroin in and out of recovery, father whose
thankfully deeply resourced, was able to spend more than six
figures in his son’s recovery, in and out of recovery
facilities. When we spoke last and when
we got to present together, most recently he has a friend
read the last text from his son. Because every communication they
had finished with, “I love you and I’m proud of you”
in both directions; that love being expressed
in both directions. And he said, “It’s
happened again. I relapsed again. I’m so sorry. I need to get this
out of my system. I love you so much. Thank you for all that
you’ve done for me.” And now his dad is
committed to change, but we look at that
situation and we go back to the very beginning, did that initial prescription
even need to happen? We’ve heard — so
year over year — and these data are
actually now a year dated. And this was very new data
last year, but year over year, it decreases in prescribing
since that peak of prescribing around 2010 where Hydrocodone
was the most common prescription in the United States;
not most common opioid, actually the most commonly
prescribed medication in the United States in 2010. And every state is
showing changes. We have every state
decreasing the number of prescriptions given, the
number of people meeting that above 90 oral morphine
equivalent threshold; maybe the only controversial
point of the CDC guidelines, but yet a point I don’t
find controversial. I don’t have any patients
in my clinic on more than 90 oral morphine
equivalents who are doing well
— we could talk about that later;
and less new starts. And so this is all positive. But then some of the
advocates in the group — and Dan has probably
experienced more of this through the HHS taskforce
will show this, they’ll say, you know, despite the fact that we’re decreasing
prescribing year over year, mortality is increasing,
and the spike in the discrepancy is
actually even greater now because we had heroin and
Fentanyl, and not Fentanyl from the operating
rooms, but the [inaudible] of the world knowing how to make
Fentanyl in their own kitchen, taking a few hundred dollars’
worth of product from China and turning it into
hundreds of thousands of dollars’ worth
of street Fentanyl. And so this is driving
prescribing. But — and so people will
take this snapshot and say, “This is proof that
decreasing prescribing won’t change mortality.” And I’ll agree and disagree. Prescribe — changes in prescribing alone won’t
change mortalities today, but we have to look
at the full picture. Dan talked about it in the
mid ’90s, Purdue Pharma, they release of Oxycontin, and
now the marketing of opioids. And not long after,
there was a decrease — there was an associated — strongly associated
increase in mortality. At its root fundamentally, the opioid epidemic is
a prescribing problem. We’ve created a supply and
supply demand issue with heroin and with Fentanyl,
and ultimately, while this can’t be
their only strategy, we have to address prescribing. Now, our group’s a
little different. When we came together about
three or four years ago, we just said, “You know,
the whole group is — the whole country is focused on
all of these downstream effects, what to do with chronic pain, what to do with
medication-assisted treatment, how to better manage the
people already using opioids. And let me tell you, these
are important topics. And we’ll actually
hear about some of these other topics today. We’ve got some great
speakers today talking about all these downstream
effects. But at that time, really no one
was really talking about this. Should we only focus on opioid
users and those patients that already have
opioid addiction, or should we also focus on
the people not using opioids, especially in the cases of
predictable opioid exposure? And what do I mean about that? If we walk over to
the University of Michigan Hospital
right now and I go into the preoperative setting,
and I say, “What’s going to predict whether and how much
opioid a person’s going to get,” there are only two factors,
what surgery they’re having, and the surgeon caring for them. And the same thing
is going to be true for dentistry and oral surgery. The case you’re having
and the person prescribing for you are the only
factors that matter. You as an individual aren’t
accounted for in any way, shape, or form, right? That’s not personalized
medicine. And this is clearly
part of our problem. Not only that, we know that
prescribing after surgery, dentistry, and emergency
medicine is more important than it once was. So these data are from
national prescribing data from a private claims
datasets — these are or privately-insured
patients. So over a seven-year period in
the top, you’ve got surgery, dentistry, emergency medicine, and in the bottom there’s
probably all others, which is predominantly
primary care — internal medicine and primary
care, over that time period, which is actually in the
preamble to the CDC guidelines. So this is before the CDC
guidelines were released, you see that the
relative contribution of who’s giving the
first prescription to people not using opioids,
that surgery and dentistry by comparison are increasing because primary care physicians
are prescribing less often. Right, so CDC guidelines
shouldn’t just come out of the blue. People were talking about it. So they were saying, “Hey, you
know, there’s something going on here, and we need to
be a little more careful with our prescribing.” My sense is that the
discrepancy will only be greater when we look at it next. Moreover, if you look at how much opioid
people are prescribing, this oral morphine equivalence,
surgeons had a big uptick when Hydrocodone
got rescheduled. So Hydrocodone got rescheduled;
we can no longer phone it in. What do surgeons do, they start
giving more in case I miss. Right, “I’ve got to
give you more now because I can’t phone it in.” The net effect of that
policy was very clear, Hydrocodone prescribed
in the US decreased because primary care physicians
couldn’t easily call it in. However, surgeons — and
we’re looking at it now, probably dentists started
increasing their prescribing. And really even if you look
over the last couple years, this last two or three
years in this dataset, there at the bottom in yellow, you see not only are primary
care physician prescribing less often, they’re also prescribing
less opioid per prescription, while surgeons and dentists
weren’t showing any change. So why? We could put just
about any head in this picture and say, “What drives
prescribing?” These are from qualitative
data from surgeons, but we’ve seen this
as well from dentists. And my sense is that even
me as a pain physician, some of these same
factors hold true. We worry about time. We worry about satisfaction. We worry about the
calls for refill, or that request for refill. And sometimes we’ve actually
put perverse incentives, we’ve linked satisfaction
and payment. And even as the age cap
measure has been removed from reimbursement, I think
providers clearly still care because they want Mrs. Jones to
go back to their doctor and say, “Brummett’s a good guy, you should send him more
patients,” to get that referral. This is still important. Well, good news, these are two
papers, but we’ve published about six or seven since, and there have been
many other groups that have shown the same thing. There is absolutely no
association between the number of pills prescribed
after surgery, and people’s satisfaction
with their care; nor is there an association
between the number of pills prescribed and the
likelihood for refill, okay? So we live in a town where
Zingerman’s is like, right — where is it, it’s like
right there, right? [Laughter] Right? How many of you have
been to Zingerman’s? Everybody been to Zingerman’s,
right, so you’d walk in and it’s kind of a
different experience. You know, it’s not just
because the sandwiches are really expensive. [Laughter] There’s
just a different vibe about the place, right? And they treat you differently. Well, I’ll give the
satisfaction example to say that our pain clinic — after
— you know, [inaudible] and I and the rest of the team
we brought in Zing training to start to revamp the way
we function in our culture, in our mission, in our
vision for our team. That spilled over
to our pain clinic; tertiary care pain facility. We tend to see refractory
patients. Our patients satisfaction
engagement surveys have been in 99.7, 98.8, 98.7 over the
last three quarters after years of sort of steady climb
since engaging them, because now we treat our
patients like customers. You know, we’re not perfect,
we don’t do everything right. I’m sure that for some of those
who have tried to refer to us, you’ve found it frustrating
at times. But once you get
them in the door, our patients are
really well-cared for. We didn’t do this by
prescribing more opioids. We did this by caring for people
like customers in a restaurant. Now, you could flip it
around and say, “Well, what about refills;
don’t they happen?” Of course, they happen. They happen all of the time. In fact, when you look at
abdominal surgery condition, they have about 70% of the time. If you take a total
knee replacement, about 30% of the patients
will get a refill. But whether you look at that
abdominal surgery and you look at the equivalent of less
than six pills of Hydrocodone, or more than 60, the
rate doesn’t change. There’s no association. You give them six
pills, they’ll call for seven percent of the time. You give them more
than 60 pills, they’ll call seven
percent of the time. And there won’t be
any differences in pain satisfaction. Well, I was really interested
in this concept, however, how often does the
person not using opioids in the year prior become
what I would call a “new persistent user”, or a
“new chronic opioid user”? And this is probably the article for which we got the biggest
splash, six percent of patients under a case mix of both
major and minor surgeries who hadn’t filled an opioid in the year prior
kept filling past — long past what would be deemed
normal surgical recovery after we have excluded
everything we could exclude in this dataset. And there was no difference between major surgery
and minor surgery. Now, some of my colleagues
were really surprised by that; like wouldn’t major
surgery be more likely, because this is clearly
postsurgical pain, right? Well, Jenna Gessling
[assumed spelling], who will be speaking tomorrow,
as some of her preliminary data for her NIH grant,
looked at some of our prospectively
collected data after knee and hip replacement. So this is from the first grant
that Dan and I had together. We looked at those patients
not using opioids prior to knee and hip replacement, and
looked six months later, and four percent of the
hips and eight percent of the knees kept using. And these are prospectively
collected data. We actually confirmed with
the patient, not using before, definitely continued
to use after. And we had the goal standard
measures of pain, stiffness, and function after knee
and hip replacement, and there is no association between whether the
knee got better, worse, or stayed the same in
people using opioids. This is not just chronic
postsurgical pain. It’s the individual that matters
more so than the surgery. Thirteen percent of hand
surgery, 13% of spine surgery — this is the only one up
there not from our group, 4.8% of teens and adolescents
undergoing elective pediatric surgery, ten percent of
curative cancer surgery, and probably our most
complicated cohort, breast surgery patients, 19% of the women
undergoing breast surgery, which is associated
with chemo and radiation as subsequent surgery. But for those survivors,
about 20% of people, at least for some
prolonged period of time, becoming a chronic opioid
user; in other words, a new source of morbidity. And I think our cancer
exception — while I am in favor of
opioids being available for malignant terminal pain,
our cancer exception is in some ways maybe
a problem of itself. Because if you compare that
ten percent to the six percent on top, those surgical — the surgical insult was
effectively the same, similar incisions,
similar everything. And this is curative cancer
surgery where we expect to cut the cancer out. That cancer exception of,
“I’m a patient, I have cancer, maybe I’m more willing
to use the opioid, and I’m treating a patient with
cancer, maybe I’m more willing to give the opioid,” we’ve
got to be a little careful with how we use that in
nonmalignant pain preface. So what are the factors that
we think are driving this? Well, these are the things
that I think really come up consistently for
dataset to dataset, preoperative chronic
pain conditions. Maybe the primary care
physicians are doing a better job of not giving you opioids for that preoperative
knee pain — or I’m sorry, for
your chronic knee pain or your chronic low back pain. You come in, you have to
have abdominal surgery, you get an opioid, and all of
a sudden, you keep taking it, but you don’t really
know that — you don’t really tell your
doctors for your knee or hip; which might initially be
better, but over the long term, their data really don’t
support the use of that opioid for that chronic pain condition. Certainly, we see anxiety
and mood disorders. And anxiety in particular
that for some patients, especially those with anxiety, it’s not that opioids
make them feel high, but they feel leveled. So when you talk to patients,
some with opioid use disorders, especially those who had anxiety
as a kid, they’ll say, “Hey, the first time I
experienced opioid, I thought I finally felt normal. I thought I finally felt like
all the other people I knew. I felt like I was
in a good space.” And then eventually, however, that can further
deteriorate mood, and then you start
to avoid withdrawal. And then although the
path is not linear, some patients fully moving down
the road of opioid use disorder. Substance use history
seems obvious. Of course, if they have
a substance use history, they’ll be more likely to
use opioids chronically. But the reality is we don’t do a
good job or screening for that, or planning for that
for surgery, and then tobacco use is
probably a surrogate. And this is not just
for surgery. I’m sure most of you have had
your wisdom teeth removed, something we do three and a half
million times a year in the US. After adjusting for
everything we could adjust for in this dataset,
including patient demographics, pain diagnoses, psychiatric
diagnoses, medical comorbidities, and the
impaction status of the tooth — I actually had to learn
the numbers of the teeth. It’s number one, 16, 17, and
32, those are your wisdom teeth. [Laughter] After adjusting
for all those factors, just being prescribed
an opioid was associated with a 2.7 times increased risk of becoming a new
chronic opioid user. And this is in dentistry
and oral surgery where you’ve had data
for years showing that opioids are not only
— probably not any better, but actually maybe even worse. If you account for side effects,
nausea, vomiting, constipation, opioids are actually worse
for post-dental pain. And yet in 2015,
80% of these teens and healthy young
adults received an opioid as a part of that care. Acetaminophen and
ibuprofen would be superior. And we’re doing this
out of convenience, and now we know there’s
morbidity. But the great part about being
in this space and in surgery — I’ll catch you at the end, okay? The great part about
being in this space is that we can certainly
improve prescribing. And so I’ll take just one — do
one example, and probably one of our favorite examples
because it was one of my first, this is gallbladder surgery
at the University of Michigan. We just wanted to find out what
was happening in our own house. If we’re going to go around and
talk about it around the state, we wanted to understand
how we’re prescribing at the University of Michigan. And this is what we found, is
that after gallbladder surgery, we prescribed the
average about 50 pills. Now, you should be a little
shocked by that, but I’m going to sadden you to say this is — these data are several
years old, probably four or five years old. In the early half of 2017 using
another national database, the average for a lap collie in
the US is still about 42 pills. Okay, so for everybody
who is telling you, “Oh, it’s all changed, it’s
all different now,” in the real world outside
of the ivory towers, first half of 2017, 42 pills for a lap collie
still to this point. So 50’s how many we gave, any
guesses on how many people took? Some of you know the story? How many — any guesses, 50s? We gave 50. You have to answer. I’m not moving on. >> Twenty-five. >> Twenty-five; any
other guesses? [Inaudible Comments] Six; six was the median. Now, 15 was going to satisfy
75% of people, and we wanted to be very conservative and so we made it 15
pills is our new number. Just said, “Hey, that
would be a great reduction. We hadn’t really done
much work in this space.” And the great part about surgery
residence is if you tell them, “Fifteen pills,” it’s going
to be 15 pills, not 14, not 16, it’s 15 pills. And so we found this
really amazing change where 15 pills became
the new average. And there was a spillover
effect, they started changing the way
they prescribed for lap appies. They started changing
the way they prescribed for thyroid surgery. I don’t know why, that seems
like it’s different spot. But they changed everything,
because they had been armed with a little bit of data. And what was cool is we saw
no change in refill request, four percent before,
three percent to follow. No change in self-reported pain. And my favorite part, we gave
them less and they took less. Now, it’s only two pills less. And so maybe in this one case,
those two pills don’t matter, but let’s project this out. What would that look
like in spine surgery? What would that look like
in knee and hip replacement? In fact, we found
this consistently in every dataset since,
using statewide data from 35 health systems,
the strongest predictor of how much people used was
how much they were given. This is a very old social
psychology construct called “anchoring adjustment”. I don’t normally start
my morning with like a — was that a cinnamon roll;
what was that thing in the — it was like really delicious,
and cakey, and probably going to sit right here for a while. I don’t start my morning
that way, but if you put it out for me, I’m likely
to eat it, right? And this idea that we can
just give people as much as they need, or
as much as they — just enough so that
they don’t run out and it won’t harm them,
is inherently flawed. This has been shown
now in every dataset. We looked at it. We’re just looking at
another patient dataset of about 1,000 patients. For about every pill you get
in excess after adjustment for other patient factors, you
use about an extra half a pill. That’s a big number. So you get an extra hundred
— you get 100 pills, after accounting for everything
you could be using an extra 40 pills, just because of
how much you’re prescribed without any changes in pain
satisfaction or refill requests. So a single intervention like
this in one health system, 370 lap collies, the
last time we checked, 35 pills less for patient. That’s like 13,000 pills
not in our community. So who are we? We’re the Michigan Opioid
Prescribing Engagement Network. We work with Blue
Cross/Blue Shield of Michigan’s value
collaboratives. These value collaboratives
are across the state. This is just an example. All 73 major hospitals in
our state, they come together on a quarterly basis
to talk about quality. And we went to Michigan
Department of Health and Human Services and said,
“Let us use this structure to get real-world
prescribing data, real-world consumption data, actually ask patients what
they’re taking, but not just from academic medical centers,
from hospitals representative of every hospital in the state
of Michigan, and then make recs. And so this — our concept is that when we make
a prescribing rec, we will see reductions
in prescribing. If we reduce prescribing
patients, we’ll reduce their consumption. And you see tons of medical
literature out there right now, especially in the
surgical world, about, “We prescribe this many,
they took this many, so this is the new number.” But the problem with that
concept is you really do have to come back and update again. Because I showed you that
anchoring an adjustment constant that anchoring an
adjustment heuristic, the idea that when we give them
less, now they should take less, it’s going to take a
while for us to figure out what the right number is, and we have to be monitoring
patient satisfaction and patient reported outcomes. And so there’s no need to take
a picture of this because it’s on our website, but
these are our new recs. We have increased the
number of recommendations. We started working with
other types of surgery. Knee and hip replacement
is our newest. Cardiac surgery we’re
seeing huge reductions. But bottom line, while these
— we’ve had some feedback, these are still too
high for some cases. The reality is these are
representing anywhere from a twofold to a
fivefold reduction of what’s happening
in the real world. And so what are our outcomes? Well, these are data from
35 hospitals in the state of Michigan, about
7800 patients. These data were just
accepted as a letter in the New England Journal. We see that our dog and pony
show what I’m doing right now is associated with about a half
pill per month reduction. This is before we
had recommendations. Just going out and talking
to surgeons about opioids and the importance of opioid
stewardship, dropped prescribing by about a half a
pill per month. And that is significantly
faster in the country. Over that same time period, it was about a half
pill per six months. So that’s great. But then we put out
our prescribing recs, and this is what we
showed to follow. Just now given data,
real prescribing recs, we see that over the kind
of immediately before this, what you can’t see on
this graph, to at the end, we had about a 50%
reduction in prescribing. And when we measure pain and
satisfaction, you see no changes in satisfaction at the
top, and no changes in self-reported pain. In other words, we’re doing
this, we’re 50% reduction across about 8,000
patients, with no ill effects. So we’re excited
about these data. There’s no doubt,
as Dan talked about, that this excess
prescribing matters. We talked about the story
of finding excess pills. But let me put this
in context — and some of you have
seen this, but if we know that about 45 pills becomes
a really consistent average and we do 1.8 million surgeries
in the state of Michigan, that means surgical prescribing
alone could be leading to about 62 million
pills per year in excess, just in our state. And just to put a visual on
it, if we think about the area of a Hydrocodone tablet, this
is what one year’s excess prescribing would look like. We’d still need about three
quarters of a hockey arena. These pills are everywhere. There are billions
and billions of pills. And we know that kids find them. In fact, when — as when kids
12 and older who admitted to misusing or abusing an opioid
in the year prior were asked, “Where did you get your
medications,” more than half of them get them
from their friends or family members;
that’s the big blue. And then there’s about 17% that have them leftover
from their own care. We now hear story of kids
pre-selling their excess pills from their upcoming
dental procedures. This is now happening;
multiple narratives floating around about this. And so we have to
get these pills out. We’re interested in
decreasing the flow. But we’ve now hosted — and
I’ll just give you the truncated version, we’ve now
hosted multiple drives. And this doesn’t
actually account for the drive we’ve just had. We’re up to about 9500
pounds of pills collected. We have a standard operating
procedure that we’ve created for how to do an
opioid recovery drive. We just started it here
in Ann Arbors as one of our community
service efforts. Now we’re up to about 50
cities throughout the state, and including the
Upper Peninsula. And we’ve actually shared this, and Johns Hopkins has
now done a couple drives. We’re probably up to closer
to 160, 170 thousand opioids, the countless benzodiazepines
and other things. But really what we’ve done —
I’ll be blunt because this a ton of work, pounds of pills
I showed you the excess, so we’ve really kind of
just scratched the surface. What we hoped we’ve done is made
people aware of the ill effects of leaving unused pills in
their medicine cabinets. We really want to put the
opioid drives out of business. We want to do new work that
gets rid of the opioid drives. And these are also new data. We randomized people to either
get usual care after surgery, outpatient surgery, or
an information worksheet where they got information
on where to find a safe disposal
spot in their community; so a very detailed worksheet
showing them how to find it. We’ve made a map of
the state of Michigan where you can either use your
zip code or just Google in, and we’ve got every
DEA-registered facility in our state in there. So we gave them that,
or the Deterra bag. Now, the Deterra bag is
an activated charcoal bag, pour in your pills,
add some warm water, and you throw it in the garbage. And we really believe this is
where you need to be, right? And what this shows
is that people who got the Deterra bag
were much more likely to dispose of their pills. And so we really want to go
back to doing other things to serve our community,
and get away from having to make this two drives a year. This has to be an
everyday activity. We’ve made information
pamphlets. I only show these to you
in case you’re interested, because we do allow health
systems to brand these. We — this is just an
example of our surgical one. You can send us a
high-resolution logo, and we’ll put your logo on the
front and send it back for free and clear use with no
— there are not ties. We have about 220 health systems in about 20 states
who are using these. And there are a couple of national societies
that have used these. This is the surgical one. It talks about what is
an opioid using safely, talks about addiction,
and on the back, safe storage and disposal. We have them for
dentistry as well, dentistry and oral surgery,
and they’re in — we have them in Spanish
and Arabic. We hope to have one soon for
emergency medicine prescribing, and for primary care
acute prescribing. We’re moving into
harder stuff now. We’re starting to do work
in transitions of care, screening for opioid use
disorder, starting to get in the [inaudible] in
our ERs and our surgery, and working with our
emergency department. And then going back
to some nerdier stuff, the stuff that I get kind of
back to my traditional roots as a classic nerd, we’ve got
about 60,000 patients enrolled in the biorepository, about
80% of whom are opioid na├»ve. And what we’re doing is trying
to link their health record to their prescription data. Actually, we’re — I
say “Surescripts” here, it’s actually the maps dataset, our prescription drug
monitoring program. This is the first time the
states ever shared that data for research with their
genetic data ask this question, “Is there a genetic association
between that exposure and new persistent use?” And I’m really excited
because it’s actually this week that geneticists are going to get the first
dataset of 27,000 people. And as I wrap up here,
I’ll just tell you about some other work
we’re actually doing. We have completely —
we’ve completed a musical. I did not write it,
that’s why it will be good. [Laughter] But we
brought in some student — we brought in some people
with their own history of both addiction and recovery, and then some parents
who lost kids. They told their stories to these
kids from the School of Music. They then went out
and wrote songs. We performed a couple
of those songs at the Harvard event last week. And it was really powerful
because one of the guys who inspired the song who has
gone through the full story of heroin addiction and
homelessness, back to recovery and is now a champion recovery,
one of the songs is about him. And I sat next to him
as he heard the song for the first time, which
was let me tell you a really emotional moment. But this musical is
envisioned to go to high schools and middle schools to teach
kids about the risks of opioids in a creative way that
will hopefully engage them. And we expect to have
everything completed. The orchestration is half done, and start to hopefully be
touring in the spring semester. So if you are prescribing right
now, or you would kind of think about what are our goals — I’ve talked a lot about
reduction prescribing. Our goals really over the next
year are to think about areas where we don’t need to prescribe
at all, completely eliminating from those cases
that don’t need it, but doing so in a
patient-centered way that manages pain
and enables recovery. We like to educate our
surgeons that, you know, there are still things
you can be doing today. Tell people pain hurts —
you know, surgery hurts. Pain is a short period of
time and you will get better, and that opioids aren’t
there to make you pain-free. We really need to educate
patients about expectations. We need to encourage
acetaminophen and ibuprofen. Benzos are a whole separate
lecture by themselves, and a huge, huge problem,
and we’re doing work there. And I am a big proponent
of PDMPs. If you don’t like PDMPs,
come talk to me afterwards, I’d love to teach you
a little bit more, because really the reality is is
that when I get into that flight on Delta, I want my
pilot to know who else is out on the runway, and
not looking at a PDMP as like just cruising down the
runway without ever looking. And I’m really proud of the work
that Apton [assumed spelling] and Jen are doing to try
to think about other ways. And I don’t know if
they’re going to be talking about this later, but they’re
really doing some incredible work to think about managing
anxiety outside of medications, thinking about really
addressing anxiety in a way that we haven’t classically
done. And so MYCarePath is
hopefully a future. And with that, I’ll just say, “How do we stop this
from happening?” Well, I think a way to do
this, we’re getting data, rewarding change,
and collaboration. These are my colleagues. Mike Englesby [assumed spelling]
is a transplant surgeon and runs Medical Education. And for those that listened to
“On Point” just this last week, he was on “On Point” talking
about Medical Education’s role in teaching patient — in
teaching these medical students about opioids and pain. It was a really great interview. And Jen Walgy [assumed spelling]
is definitely the smartest and most effective
member of our group. She is hard, hard-working
and just super-effective. And this picture’s
probably even dated. We’ve grown pretty quickly
over the last three years. Really exciting group, and a
lot of collaboration with others in this room [inaudible]. You can go to our website
to find more information about our prescribing recs, our patient materials,
and our future work. Thank you. [ Applause ]

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