Transforming Virginia Medicaid’s Addiction and Recovery Treatment Services (ARTS) Benefit

MARCIA DAY CHILDRESS:
Good afternoon. I’d like to welcome you to
the Medical Center Hour. I’m Marsha Day Childress
from the Center for Biomedical
Ethics and Humanities in the School of Medicine. And we’re delighted to
see all of you here today. The Jessie Stewart
Richardson Memorial Lecture, which this is, was created
at the University of Virginia School of Medicine in 1999. Since then, this
lectureship has sparked a sustained conversation
here on the sensitive subject of communication
about medical error, its myriad repercussions for
patients, families, and health professionals, and its impact on
the safety and quality of care. This lectureship
remembers Mrs. Richardson, who’s untimely death
nearly two decades ago was a result of tragic,
adverse events in her care at this hospital. Because Mrs. Richardson
was a teacher, her family, quite
remarkably, chose to invest funds in
medical education so that upcoming generations
of health professionals at UVA might know better how to invest
themselves in care that truly has the patient at its heart. This afternoon,
as every year, we welcome to the lecture Mrs.
Richardson’s son, Dr. Don Richardson. We welcome also
several other members of the Richardson family today. We acknowledge both
the family’s loss and their generous gift and also
your continuing collaboration with us. We appreciate it much. The annual Richardson
Lecture constitute an evolving
conversation on a couple of themes with considerable
currency these days. One theme, medical error
and patient safety, has been addressed several
times by leading experts. But another theme
right from the start has been attention
to the patient. This year’s lecture
extends the idea of the patient to encompass
citizens and communities and to embrace a
public health crisis. the opioid epidemic that
is exacting a terrible toll on health, lives, safety,
and individual and communal livelihood across Virginia. This crisis calls on elected
leaders, policymakers, health care institutions,
community service agencies, and individual health
care practitioners to take notice, take
action, take care. In the written words a
playwright Arthur Miller who wrote these in reference to
another tragic situation, that of salesmen Willy Loman,
“Attention must be paid.” This Richardson Lecture
aims to do just that. We welcome today the Honorable
William A. Hazel Jr., secretary of Health
and Human Resources for the Commonwealth
of Virginia. Secretary Hazel will discuss
with us Virginia’s approach to the epidemic in
policy and practice and the impact that
approach to date. Following his presentation,
we will briefly hear local perspectives from
UVA primary care physician Dr. Mohan Nadkarni and from
Region Ten Community Service Board representatives Marny
Bentley and Rebecca Kendall. You will find
biographical information about all speakers
in your handout. And please note that
none of the speakers had any conflicts on
interest to declare. I’d like to thank the Office
of Quality and Performance Improvement for partnering once
again with the Medical Center Hour for the Richardson Lecture. Secretary Hazel, welcome. WILLIAM HAZEL JR.: Thank you. [APPLAUSE] Well, good afternoon
to all of you. Doctor, thank you for
being here to do this. We were speaking
earlier and what we’re going talking
about today is this opioid epidemic is, in
large part, our epidemic. We did it. We did it because of
compassion for people with pain, perhaps, a little
inattention literature and studies, growing consumerism
in health care and driving people to manage the pain to
avoid bad comments in media and so forth. And we were slow to pick
up what was happening. We also did it
because we believe in the patient-physcian
relationship and we believe that our
patients love us and always do what we tell them, right? Yeah, glad we got over that. So I’m an orthopedic
surgeon by training. I practiced for 20 years before
becoming secretary in 2010. And I can tell you that
the education since then has really added to my
understanding of all things that I did wrong in
this particular setting. So let’s start. This is a map, 1999. Most will recognize
the United States. And please notice
these little red spots. These are death rates
from opioid overdoses. This is 2004. This is CDC data. This is 2009. Red is bad. That’s not a
political statement, I just want you to know,
not a political statement. Red is bad, OK? And then 2014. And you all did just
what most audiences do. Ah, we should know this,
death rates from opioids. If you show this to a
political science person, they might look at this and say,
you know, that looks familiar. Any political
scientist doctor here? Some would say that resembles
the Trump electoral map. And I don’t mean that
in a political way, but there is
something about parts of the country where it just
isn’t working for people like they expect it to. And this has been referred
to as a map of despair. We’ll come back to that. So how does this
impact Virginia? Well, this is a map of
Virginia and environs in this. These are opioid
prescribing rates. 2006, we don’t
have exact numbers, but look at prescribing rates. Notice this area down here. This is West Virginia,
Kentucky, Tennessee is here, North Carolina. Look there. And, of course, you’ll pick
yourselves out right here. And this is 2011. And look at the increase,
even after OxyContin, we were aware of problems,
the rates are increasing. And fortunately, we see
a little turn by 2016 and we think some of
that has leveled off. But when you look at what
people die from in Virginia, this is the death rate
from opioid overdose, prescription overdoses here. And look down here. It matches up. These are prescribed,
legally prescribed medications that
were either given in an unprofessional fashion,
dispensed unprofessionally, sold, diverted, et cetera. And if you saw 60
Minutes on Sunday night, you probably saw another
piece of the puzzle. I wish I could say
it surprised me. I was telling Dr.
Richardson, there are things you
learn in this job, if you remember Toby
Keith had a song back in the day and the
refrain was, “I wish I didn’t know now
that I didn’t know then.” And I wish I didn’t know
how bad it was from what has happened in that industry. And this is the
rest of the state. And why I show you this is
because we think about policy, we don’t think about the
University of Virginia, we don’t think about
Charlottesville, we think about the state. And this is the same
problem every place. And when you look
at the country, it’s not the same
problem every place. And so when you’re
working, what on earth are those people in
Richmond trying to do? We’re trying to consider
the whole picture. And that does make a difference. We’re seeing a change in drugs. Last year, we know 1,133 deaths
that were opioid-related. What we’ve seen
is a leveling off of those related strictly
to prescription medications and an increase in heroin. And I think the
increased death rate is due to what the heroin
is adulterated with, the fentanyls and the
varieties of those. We’ve even seen carfentanyl. And for those
non-medical, carfentanyl is used in veterinary
surgery for elephants. Carfentanyl, when dusted on
a police officer’s jacket will send them into overdose. We need to know these
things very quickly. So you can see
the rates changing on this year, the
trajectory, we think can surpass that
year or last year. And you can see what
is happening from this. Likewise, these are the
total number of fatalities. And if I wanted to go back,
this is all drug overdoses. And it’s important to note,
there are more here than this. Because we think of this
as an opioid epidemic. It’s an addiction problem. And the difference here is
cocaine and benzodiazepines, methamphetamine. If you’re in Galax,
opioid is what? It’s methamphetamine still. So as we look at this
and we sort of in policy take advantage of
the opportunity to build a system to address it,
you have to address addiction. Addiction has been with us. We’ve had alcohol and tobacco. And I would guess more
people are dying today from alcohol-related issues
and tobacco-related issues than opioid-related issues. But what’s on 60 Minutes? It’s opiates. So what we can do in the
policy world is look at this and say, all right, how can
we build something that fits? Because these
drugs are changing. The drugs that
are coming in now, if you saw the news
last night, they’ve identified a guy in China
that’s selling fentanyl and it’s delivered
by UPS to your house. OK? That’s what’s happening. And I would
recommend if you want a good history of the epidemic,
there’s a book called Dreamland by a guy named Sam Quinones. Sam was a reporter,
investigative reporter for the LA Times. And he does not give me
royalties for advertising it. Though he does owe me some. You can see the fentanyl
and heroin ratios that have increased over time. And I just throw
these up quickly. The widest matters,
and I think when we need to think of in a medical
setting is, what are we not picking up and why
are we not addressing as I become highly specialized
as an orthopedic surgeon? And you can laugh at
that, Dr. Richardson. He doesn’t seem to think
orthopedic surgeons are really that specialized, but– I’m used to taking it. It’s OK. But, you look at this and what
we see here, hypertension, this is no mental
illness, no drug/alcohol but look at the number of
people with hypertension who have a comorbidity,
a co-occurring condition. And look at where we fit in to
both drug or alcohol addiction. And you can see this
for multiple diseases. And where that
impacts us is look at the cost when these things
overlap, very significant. Now, asthma, COPD,
congestive heart failure, coronary heart
disease, diabetes, when you have mental
illness or substance abuse of one type or another,
the costs go up. And what is the rap if
we have in health care? We’re too expensive. That is the underlying
dynamic that will drive policy for
the years to come. We are too expensive. We spend 18% of our
gross domestic product on health care. Switzerland spends 12%
and covers everybody. And as far as I can tell,
the Commonwealth of Virginia has lost no jobs to Switzerland
in the last 10 years. That is where we play
into this and why we have to begin to address
these issues more aggressively than we have in the past. And just for kicks, I’ve
thrown in another slide that shows the place where
I think we might be missing the boat a little bit. This is from Ben Miller. Ben is at the Farley Center
at University of Colorado. He’s a psychologist. And he’s done work with
integrating behavioral health into physical
medicine, which is what we need– we need to reconnect
the brain with the body. When the orthopedist
doesn’t do that, because they say the
orthopedist’s brain isn’t connected to begin with– Doctor, I’m sorry– but
when you don’t do that, you treat the pain in
the knee and forget about the addiction problem
or the mental illness or the other problems that
go on with the patient. So we have to bring
those back in. But This suicide rate– and I
showed you the map of despair. There are other things
going on here that we need to also take into account. And those are
social determinants. Is everybody here– is everyone
here familiar with the term social determinants of health? Raise your hand if you aren’t? OK. So what social
determinants in health say is that there
are things that happen in your
environment, your genetics account for some of your health,
what happens to you determines how your genes
express themselves and other trauma that occurs. We know children exposed
to certain conditions will have physical
changes in the brain, leads to behavioral changes,
leads to physical illness later in life. We’ve known this in
medicine for 25 or 30 years in the pediatric world. So we have to realize this. And if you don’t believe in
social determinants of health, do you believe in social
determinants of life? And I’ve had people
in audiences say no. And let me– I’m
going to tell you, there are– going to show
you and you will get this. Two four-year-old
boys, this little boy is from the west
end of Richmond, this little boy is
from Gilpin Court, which is a public
project in Richmond. They are four years old. I’m not contained
anymore and that. Can you take– just
by that information– how life is going to turn
out for each of these kids? You already know
what they look like and you’ve already judged that. So these things matter. These things matter. And we have to be
conscious of it. So what are we doing about this
epidemic at the state level? And I typically think of
this into five buckets. And the first bucket
is harm reduction. As long as people cannot access
treatment because it’s not available, they can’t afford it,
or they’re not ready to accept treatment, there will be harm. Then we have to make
treatment available. We’ve got to think
about prevention. And we have some issues
of culture change. And so what we’ve
done, clearly, we’ve made Naloxone more available,
trying to save the lives. You can’t help
someone who’s dead. We have looked at
syringe exchange around the issue of hepatitis,
HIV, and endocarditis which has increased. It is endemic in areas where
needle exchanges occur. We have seen an
increase in the number of children coming into
foster care due to addiction. Foster care is one
of my agencies. So we’ve seen that leading
cause of family disruption. We see the neonatal
abstinence babies which cost $60,000,
$70,000 a pop before they even
leave the hospital. And who pays for all that? Now, this is the call and
response portion of the sermon. [LAUGHTER] So I’ll just tell you the trick. When I say who pays, you
all say, we all do, OK? So who pays? AUDIENCE: We all do. WILLIAM HAZEL JR.: We all do. And the reason we do is because
if these people don’t have jobs and aren’t earning
income and they’re coming in here to the University
of Virginia for health care, it’s still not free, is it? We all pay. Hold that thought. Hold that thought. Because then we have the crime
and the folks who get picked up and they go to jail. And we have the unemployment
and lack of productivity. And all of these
things are the harm. And unfortunately,
[INAUDIBLE] I can’t measure the harm in the community. I can’t quantify it. So when you go lawmakers and
say, we need to expand coverage and we need payment for this–
but it costs $1,500 per person a month in Region
Ten to get MAT. I say, but how much does
it cost to do nothing? That’s the value equation
we need to think through as we look at this. Treatment does work. It works about as
well as it does for lots of chronic diseases. This is from Mishka
Terplan at MCV. I think you all can accept
that it’s from out of town, but it’s still good data. And what we have
done is we have tried to make medically-assisted
treatment more available through our ARTS waiver, the
Addiction Recovery Treatment Services waiver which includes
such novel things as paying for peer engagement. We started this in April. We’ve had an increase– I’ll show you a
slide in a minute. But I wanted to point out that
our effort here with substance abuse treatment
includes building on physical medicine,
laboratories, peer engagement, I mean, all of these
pieces that are important to look at
the patient whole, integrating this together. In fact, we– it’s odd. We just began partial
hospitalization in residential treatment
in October, not in April. But that’s budget. That’s strictly driven
by how much money we can get through the
General Assembly to do this. And these are
issues that we have. And we have seen an
increase in treatment. This is the ARTS waiver,
what’s all involved in it. And you can have the slides. And we’ve seen a
significant increase in the availability
of treatment. Now, it’s not perfect. I understand, well, rumor has it
there’s not quite enough of it in Charlottesville,
but we’re working on. We need it [INAUDIBLE]. So that’s one
thing, but we still have complications–
for instance, as long as there are methadone
clinics out there that are taking cash,
some people find it’s to easier to pay the
money, steal to get the money. You buy the methadone tablets. And you don’t get the assist. And the assist is the keyword
in medically-assisted treatment. It’s the social supports
and the wrap-around. It’s just like AA and NA
and these other groups that help people
stay in recovery. Without it, it doesn’t
work for most people. So it’s important
to recognize that. Here we’re thinking
about prevention. And this raises the hackles
of a lot of physicians, but we are the ones that
have poured the pills out. Some of it are
really bad guys that need to be taken out of the
profession, and some of us are really good people trying
to manage pain in the best way we know how to do. And pills are still getting
into the system and diverted. Rarely do I leave an audience
and talking about this who someone said, I went to the
doctor and I got 50 of these and I took two, what do
I do with the other 48? These are things we have
not paid attention to. And these pills are out
there on the street. An aha moment for me was we
had a pharmacist come and say, you know, when people
die in hospice, sometimes they haven’t filled
the whole prescription. And after they’re
dead, their family comes in to get the rest of it. I mean, do you
know that happens? We don’t think about that. Good people– we don’t think
people do this, but they do. And that gets diverted. And when your brain is
overtaken by addiction, Sam, the author of the book
says it’s like this is the classic American problem
is the overwhelming urge to find a product that
will solve life’s problems. And then the product for
these people who are addicted is opioids. And that’s what we’re
up against here. We put in prescribing
regulations following the CDC guidelines. We have put in some
requirements about utilizing the prescription
monitoring program. And last year, the Medicaid
program did something unique. We eliminated– we put in a
preauthorization requirement for opioids, but we
dropped the requirements on things like lidocaine
patches and neurontin and so forth that
are alternatives. And look what happened. We saw a decrease in the number
of pills going out with a only a slight decrease in the number
of prescriptions written. We think that it is
better prescribing, and we would hope that’s
what this indicates. The impact of the
regulations that went into effect in January,
following the CDC guidelines, significant reductions in
morphine milligram equivalents that are going out
in three months. So those who think government
is hopeless, it doesn’t work, you may say we
shouldn’t do this. And there is risk, because
people are still addicted. If they’re not in
treatment and if they don’t get their narcotics,
they go to the street. And nothing on the
street is FDA approved. And they don’t know
the fentanyl is in it. They take it and they die. That’s the risk
we’re writing as we try to balance this
treatment/prevention paradigm going forward. But the morphine milligram
equivalents has gone down. This is– have to look at this
number of prescriptions written down– I have to catch up
with my slides here. The doses dispensed
by drug type, and notice that they’re
tranquilizers, stimulants, and sedatives are all here and
they all play a part in this. And so we think we’re
getting the effect. This is buprenorphrine
prescriptions and Subutex mono-product. The mono-product is abused–
down in southwest Virginia where you saw that
avariant pattern. The judges there do not want
medically-assisted treatment in drug courts because
the people are often arrested because they
are breaking and entering to get the mono-product. And, you know, we’re
telling everybody you don’t get high from
it, but their experience is it’s different. It’s different in different
parts of the state. So we put this in last year. And you can see– it’s– we can
see that the mono-product has dropped and the
buprenorphrine has increased. So we think we’re
making progress. And we’re following
that data very closely. And those rates which should be
final, permanent, final rates at the end of next year. Because the emergency
rates are in place. The next area that I will
get into just briefly as we continue to work
with law enforcement, this is a
multi-disciplinary attack. We have a management
structure that the Secretary of Public Safety and
I oversee that brings all the agencies engaged in
the opioid epidemic together. And we are trying to align. The biggest issue is
information sharing. There are rules. Every agency has different
rules– some of them are federal, some are
state– that prohibit us from sharing information. So we’re working really
hard to break down some of these barriers
going forward so we can– we can get to
communities more quickly, we can position
resources more quickly, and we can chase the bad
guys more aggressively. The next area that we talk
about is really culture change. And there are three
pieces to this. And one is dealing
with the perception that prescription drugs are
not as– are not harmful. Kids get these things
out of medicine cabinets. They take them. You’ve heard of the
pill parties on Friday nights and things like that. Legal and safe are
not the same thing. They’re not. And our schools have no
real organized program even to educate the kids what
their parents don’t know. If you ask, they
will tell you, there are programs that
fit into the SOLs, but they’re not in
most communities. And that’s something,
I think, we need to really work at because
that’s the only place we’re consistently getting
kids and have a chance to do it with families. The next thing we
have to think about is how we deal with
pain as a culture. When I did surgery in Bolivia,
I did 25 joint replacements in Bolivia back
in 2001 and 2002. No patient took a
narcotic after surgery. And interestingly, I don’t
think any one of them had any opioid-induced
constipation, not one. [LAUGHTER] All right, so, but they got
up, they didn’t have fevers. You know, it was
hard to say it’s a real study– the
language difficulties, cultural difficulties. But I’m telling
you, these people got up and moved and went home
and didn’t have the problems that we see typically. It changed my approach
that I dealt with. But there are cultural issues
around pain that people think we need narcotics and we don’t. There are other alternatives. We still– there’s still
more research to be done. And there still is a
place for narcotics. There’s no doubt
about it in my mind. But we have to be judicious
and think carefully about how we use it and some
of the other medication. And then I think the third thing
or the final piece of culture change is we’ve got to
figure out how to help people stay in recovery. And this is the social
determinant piece. If you are addicted– and
the challenge we have is now we have people who are addicted. And they will– three
things can happen to them. They can stay in
active addiction with the harm it causes. Did I ask you all
who pays for that? AUDIENCE: We all do. WILLIAM HAZEL JR.:
Who pays for it? We all do, right? So they stay in
that or they die. Sometimes it’s merciful,
but it’s not an outcome that we aspire to. Or we help them
stay in recovery. But if you are in recovery,
and let’s say this demon, it took over your
brain, it’s driven you to create acts
to support your habit and now you have a record, what
are your chances of getting housing? What’s the first thing that
happens when you get a job? Drug tests. And these are things that
are important to know. And it’s not that you
want to say it’s good, but how do we think about a
work environment that actually supports people in recovery
instead of bans them. Think about that for just a
minute and how we do that. These are things that we’re
still trying to address. Think about what happens
if you can’t get a job and you can’t support housing
and you can’t feed yourself and you can’t pay
your child support. Who pays for that? AUDIENCE: We all do. WILLIAM HAZEL JR.: Yeah, so I
think that’s the lesson here that we all have to think
about as we go forward, I will point out
one other thing. We do have– we were assigned
by the General Assembly to create a curriculum
around pain management and opioid
dispensing, Department of Health Professions’
David Brown has led that effort for us. A lot of the universities
and different groups have been involved. But we’ve taken the medical
professions, nursing professions,
prescribing professions, and created a curriculum. And now we’re socializing
that with the non-prescribing professions– psychology, social
work, and so forth. Because we want, at
least some common understanding in all of
our areas of intervention. I mentioned the social
determinants of health earlier. I won’t come back to this. I will tell you that
there is some evidence that there are factors
in play that can protect. We think about trauma in a
term, as an orthopedic surgeon, trauma was when the linebacker
hit the quarterback. But trauma in the
world I live in now is what happens to these
kids and these young people that, when they have adverse
childhood experiences, it’s what happens
to our veterans when they come back from
war zones and so forth. And not everyone who has
trauma has a bad experience and permanent changes from it. And there is such a
thing as resilience. And we can build
resilience in communities by establishing relationships,
sense place and so forth. And there is evidence that this
work– this isn’t necessarily what we do in the hospital,
but it is absolutely essential. Because you can take that person
with diabetes and send them back out. What happens? Nothing’s changed out there. They come back over
and over again. Same thing happens
with mental illness, which is a huge
issue we’re dealing with in the
Commonwealth right now. And obviously, substance abuse. So I’ll leave you with this
slide, this slide by Einstein. What we’ve been
thinking that got us here is not going
to lead us out. We’ve got to think as
medical professionals how to interact with that
community differently and how to ensure that
programs are in place. And then one additional
thought from Ben Miller. So many of the people who
have adverse consequences from their addictions
and their mental illness are in medical care
and nobody knows. And we need to rethink that. So thank you. Mo, the floor is yours. [APPLAUSE] MOHAN NADKARNI: Well, first
of all, thank you very much, Marcia. Thank you Secretary Hazel. And thank you to the
Richardson family for sponsoring this program. When Marcia first asked me
to sort of gather my thoughts from the perspective of
a primary care physician, I actually found it
very, very cathartic. In fact, you’ll probably
see from my remarks that I’m very conflicting. In fact, I worse this tie. If you can’t see,
it’s The Scream because that’s sort of
the conflict it develops. And in fact, it’s so
conflicting that I also wore The Scream socks. [LAUGHTER] So I’ll first start
by asking you– WILLIAM HAZEL JR.: There’s
probably medicine for that. [LAUGHTER] MOHAN NADKARNI: So I’d start by
asking you, who in the audience has ever used a single
pill or shot of opiate, perhaps in the setting of
some acute injury or surgery. Raise your hand if
it’s ever happened. For me, an ACL repair in
med school, the anesthesia started wearing off, I got a
10 milligram shot of morphine. The pain was gone. And then who among you has– or, actually, looking at the
age in the audience, who has not had low back pain and sometimes
that sort of gripping pain– WILLIAM HAZEL JR.:
Since this morning? MOHAN NADKARNI:
Since this morning. That sort of gripping
pain that keeps you from rising, that only sort of
goes away with some acute pain therapy such as Vicodin. Me And then I’d ask you,
if feel you comfortable, how many of you in the audience
have ever struggled yourself with addiction or have had
someone with addiction touch your life? And if you look
around, you’ll see that there are more than
a– more than a few hands. So opiates are now cast sort
of as the ultimate evil, just as they were cast
as the cure for salvation when I was training
in the 1990s. As Dr. Hazel mentioned,
the mantra was, “pain was is the enemy” and
pain was the fifth vital sign. We needed to take care
of pain no matter what. Well, we’d now like
to think that caring for opiate-addicted patients and
the approach to opiate therapy is pretty simple. Well, it’s simple,
but it ain’t simple. The interplay between
chronic pain and addiction is one of the most
mind-bending conundrums that a primary
physician can face. Now, sometimes it’s
really simple like when one of my opiate
contract patients had a positive urine
test for marijuana. I In call her up,
report the results. She said no, no, that’s
impossible, that’s impossible. I couldn’t be positive
for marijuana. The person I bought
that urine from said that there is– not
been using in two months. So that’s a simple decision. There we, we
stopped the opiates. But sometimes it’s
not so simple. When the chaos of
someone’s life combined with nagging chronic
pain and severe anxiety and cries of anguish emerge,
when the physicians need to help a suffering patient. So I ask you, what do you do
when the ibuprofen, naprosyn, the voltaren gel, the
Tylenol, the Lidoderm patches, the gabapentin,
the zonisamide, the Topamax, the Lyrica, the Cymbalta, the
capsaicin cream, the trigger point injections,
the physical therapy, the epidural steroid
injections, the chiropracty, the acupuncture, the
mindfulness, the magnet therapy, the crystals, and the
OK, we’ll try some Tramadol. Oops, they’re
allergic to Tramadol. Anyway, those things
don’t work for the pain and the only thing
that seems to do is the oxycodone which
works either for pain or for something. So which of the literally dozens
of patients with chronic low back pain that I’ll see
in a week is the one that returns to full
work and realizes a superior functional status? And which is the persons for
whose needs for opiate relief is no less urgent
to the patient, but lies more in the
realm of addiction? And which of the patients is
the grandmother– a true story– who had bad arthritis,
kidney disease– so we can’t use NSAIDs– whose Vicodin really
does help her pain, but she forgoes
it so she can let her son sell it so he can afford
his expensive new insulin? It simply ain’t simple. Now, people like lists and our
Epic electronic medical record lets us build lists. So I happen to
have a list for all of my current narcotic
contract patients, about 20 out of the 500 or 1,000
patients that I take care of. And I reviewed my own list. And I found about 15 patients
like Mr. T– not the, “I pity the fool”
Mr. T, but he’s an 80-year-old soft-spoken
African-American man I first started caring
for about 20 years ago. And as his arthritis
has progressed, he now comes in for about 90
oxycodone pills every three or four months and is
proud that at age 80 with the occasionally help
of a pill before he plays, and he’s able to bowl
an average of 200. But then, looking at the
list, I also found about five to eight, what I would consider
sort of borderline patients who had this nagging
sense in my gut were using for reasons
other than or in addition to their chronic pain. And then there are the ones
on the list whose names you dread to see when they’re on
the scheduled for the next day. For instance, a woman who
survived 80% burns on her body as a young adult, lost her leg
to infection three years later, requiring an amputation,
that has chronic reinfections of her leg stump,
chronic pain in her leg, and she comes back to you
having been provided high dose opiates for two years that
were started elsewhere. And she tells you that
she continues to suffer. And by the way, she was raped
when she was 12 by a relative. You know she’s in
pain, but you also know that she’s been
escalating her oxycodone use. You try to taper the
drug, but she comes to you in tears begging you not
to let me suffer anymore. Have you no heart? Aren’t you supposed
to treat pain? Haven’t I suffered enough? What do you do then? And it doesn’t even end there. You look at another
list, a line called “Nadkarni former
contract patients.” You chuckle over the one
who had the fake urine, but you notice that most
of those patients who had inappropriate contract
med screens are simply are gone up from the practice,
not having taken up your offer for connecting them with
some sort of substance abuse treatment and not receiving
health care that need. And it doesn’t even end there. You look down the list further
and you look after 25 years and you see the names
of those six folks you treated only to lose them
to some sort of sudden death. And you’ll never ever
really be sure whether it was that compassionate care
with opiates you provided that sent them to their death. And it’s sickly. You know, I have to
say, there’s sort of a certain amount
of relief that occurs when a urine
drug screen comes back positive for cocaine. No moral dilemma there. It’s not like the guy who I
had who was sort of totally straight for 10 years,
but just got back from Colorado a week ago. Client said he was
just at a party where’s there’s a lot of
marijuana smoke around. Should I take him off opiates
or not when he tests positive? Well, you think
cocaine’s positive, now we can finally fire this
patient from the contract. How wonderful, how glorious,
another patient I can take off opiates. The problem is, if you really
want to treat the patient, you really need to get them
into addiction therapy. And that’s what’s
difficult. It’s really the hardest part of taking
care of the patients who do have the addiction. We really need to
do more than stop– than just stop the
opiate contract. We really need to provide
seamless treatment for patients. I’m really pleased to see
that Dr. Hazel and DMAS are encouraging addiction therapy
for Medicaid patients. And it certainly will take
enhancements in reimbursements and a whole lot of other things
to combat the pernicious plague of this addiction. But the fact is, access
to substance abuse care is woefully inadequate
in our community now and in our hospitals
across the nation. It makes you think of the
Little League baseball player you coached at age 10
whose parents desperately call you 12 years later
seeking an immediate visit because his dependency
has developed after he got treated for an accident
with neck pain and chronic headaches. They wanted to have
medical therapy, but he can’t afford the
methadone maintenance clinic price of about $700 a month nor
the higher prices of the three local practices which
provide suboxone therapy and they can’t wait for the
UVA suboxone clinic which has a six month wait
list because it’s only open a half day a week
staffed by a lone addiction specialist who is supplemented
by some psychiatry residents. So what do you? You spend the afternoon you
thought that you had off and you bargain back and
forth with your buddy who does prescribe suboxone
to take this patient on an compassionate care basis. And luckily, nine months
out, he’s still, still sober. Or you take the case of
the 30-year-old woman with severe depression after
losing her young infant who ended up turning to heroin to
ease the pain, who on and off over the last five years has
been intermittently using and then asking for help,
trying to get methadone, going back to using. And just two weeks
ago, at UMA clinic, I saw her with a resident
who had been trying to get her into a therapy. She had been 13
days off of heroin. She was very, very proud of that
and begging, begging, begging, in tears for suboxone therapy. Again, only through
the fact that I happen to know the suboxone
addictionologist in psychiatry who is a wonderful person,
I was able to get her paged and we ended up getting her to
take an appointment after two weeks. But that was only because
there was a special page and she happened
to answer her page and there happened to be maybe
one opening two weeks later. So it’s really
shouldn’t take a miracle to get someone into treatment. So it makes you wonder
if our system is really set up for compassionate care. Is a system where literally
hundreds of addicted patients struggle to get ARTS therapy
really compassionate? Is a system where the
fastest way to get detoxed is to be incarcerated at our
local jail actually effective? Now, primary care,
lately here at UVA there’s been the
beginning of this debate. Should all primary care docs
get trained in suboxone therapy and get licensed? And I can tell you, there’s
much angst over this amongst my colleagues. We go back and forth . Many of us don’t
want to take this on knowing that the time,
the effort, the mental energy that this will
consume, whether it’s going to influence the
population that we’ll see and influence our trainees
not to go into primary care because of the patients
they’ll be seeing. And it’s fascinating,
you know, nobody ever tells a primary
care physician, you know, there are not
enough cardiologists, so why don’t guys teach
yourself how to do cardio caths and then you can take care
of your patients the way you’re supposed to. We don’t hear that too often. But we hear it about opiates. Really it’s very simple. ARTS therapy needs to be
available and straight forward. It’s something as
simple as hypertension therapy or Botox
injections or LASIK surgery or even insulin itself. But it’s not so simple. The numbers of the
primary care [INAUDIBLE] is dwindling under the pressure
of bureaucracy and paperwork. And most are unwilling to
take on ARTS therapy no matter whether or not they do
have ancillary support. The number of trained
addiction specialists, both physicians
and non-physicians is dwarfed by the growing needs. So I hope ARTS therapy
becomes available to all. And I commend Secretary Hazel
for pushing the agenda that’s long been shoved under the rug. As my community
colleagues will show you, it really takes a
multi-disciplinary approach to tackle the
problem as described. And we’ll need to all
join forces to do that. But it’s more important that. Until we address the social
determinants of health, which have already been discussed,
such as housing, health care access, poverty,
educational access, we can’t really expect
the epidemic to cease. This epidemic is
really borne out of the soul of social injustice. And if we in our ivory
towers bury our heads, focus only on our small
areas of health care, and wait for others to
act, we’re bound to fail. Some say the road to hell was
paved with good intentions, but I would say the indifference
to the suffering of others– be it pain, be it addiction– is the true road to hell. And I recently
heard a podcast that quoted Eleanor
Roosevelt as saying, “indifference is cowardice,
but courage is exhilarating.” So there’s really only one thing
that is simple to remember. The boiling vat of chronic
pain is overflowing, the sea of addiction is
endless and overwhelming, but the time to act
courageously is now. Thank you. [APPLAUSE] MARNY BENTLEY: Thank you. Thanks for inviting us. I’m Marny Bentley
with Region Ten. And I was asked to
talk a little bit about Region Ten’s
implementation of the ARTS program and our services. So as you can see and as
we’ve heard today already, the opioid epidemic, we’re
seeing that as individuals are coming through our doors. We’re seeing the demand
rise dramatically over the last four years,
four or five years. And so we’re trying
to meet that demand. Prior to the ARTS
implementation in April, an individual coming through our
doors with opioid use disorder would have been offered our
intensive outpatient groups, which is about nine hours
a week of group therapy along with individual
therapy with that. We actually had to
expand that in the fall of 2016, even prior to
the ARTS implementation, due to the demand that
we were seeing even then coming through our doors
that we over more than doubled our capacity in that
realm before that. The reimbursement rates
for that prior to ARTS were quite low, not meeting
the cost of the service. As you can imagine, nine hours a
week of clinical time is great. Before ARTS, the
medication-assisted treatment was– we were private pay. So they would be paying upwards
of $700 to $1500 a month if they wanted to receive
medication-assisted treatment prior to ARTS implementation. So for many, that
was out of reach. Prior to ARTS
implementation, Region Ten implemented what we’re
calling OBOT, Office Based Opioid Treatment, which is
really kind of a wrap-around. They talk a lot
about the assist in medication-assisted treatment. It’s not just the medicines,
it’s the wrap-around care. So they get substance abuse
case management, therapy, and the medication
all in one place. IOP reimbursement rates
increased dramatically with the ARTS implementation. And then, it is
still to note for us, 70% of our substance use
population is still unfunded. They’re not eligible
for Medicaid, and they don’t have
private insurance. So even with the
ARTS implementation, that helped a portion
of our population, but there is still a growing
population out there that do not have Medicaid coverage. And we are not
providing, at this time, subsidized medication-assisted
treatment just because of the cost of that program. It is a wrap-around service
with a physician and a couple clinicians that provide a
high intensity level of care. So now let’s talk briefly. We wanted to give a
snapshot of a consumer that has been affected by
the ARTS implementation. So we have Leslie who has
a long history of substance use, chronic pain,
as we’ve heard today, prescription drug use
along with other drug use– drug misuse. She’s also diagnosed with
major depressive disorder and PTSD from adverse
childhood trauma. Let’s see if I can do
this at the same time. Due to her drug use,
she’s had multiple charges for drug possession
and has done time in jail in the legal system
and has been on probation for many years. She’s had many episodes of care
with Region Ten, outpatient as well as residential
detox and residential care. Most of those failed attempts
due to her complex needs. Eventually, she was entered
in the drug treatment court program which uses our
intensive outpatient care. She eventually failed
out of that program also because her
complex needs, so wasn’t able to even meet it with
that wrap-around type of care. Her children were
removed from her care. And part of– so this
is one of our consumers that has come into
the OBOT program. And since that time, she’s
been sober for two months. She’s regained custody. She’s in the process of
getting custody of her child. She’s got visitation and
she’s working towards that and she’s working towards
gaining employment. So it really has made
a vast difference in her life to have the
appropriate level of treatment. We had to go back and forth
with her probation officer. We have the stigma of MAT
even in the providers. Her probation officer
did not want us trading one drug for another. So we had a lot of
discussions about getting her into treatment and
allowing her this one last chance for treatment. And for her, it seems to
have been what was needed. So now I’ll let Rebecca talk
about the system approach quickly and then we’ll be done. REBECCA KENDALL:
So as you can see from this story about our client
Leslie as well as Dr. Hazel’s presentation and
Mo’s presentation, it’s a complex issue. And there’s lots of pieces
to the opioid puzzle. And this is– is really–
it’s a systems issue. So the Institute for
Healthcare Improvement did a scan of all of
the opioid initiatives throughout the United
States to really look at what is critical
for implementing an evidence-based,
effective approach. And what was found is that
a systems approach is really what is required. So there is supply issues, what
are the prescription rates, how are prescriptions being made. There’s diversion
issues within that. There’s public
awareness about opioids. There’s how do you manage the
opioid-dependent population. And then there’s
access to treatment. We’ve heard about all
of these things today. So we just wanted to
share a little bit more. So Region Ten is providing
medication-assisted treatment to a segment of our
population currently since we do not have
the resources for folks that are insured. But in addition, Region Ten
and the Community Health and Wellness Coalition
are also working on a number of other drivers
of the opioid epidemic. So we wanted to be sure to talk
to you a little bit about some of those options and what
we’re doing here today. So we have a small
prevention grant that we’re working to
help promote awareness around safe drug storage
and safe drug disposal, very happy to be looking forward
to a drug disposal site here that’s coming. We also have information about
sites in outlying counties. So there’s a handout up
on the table on the way in I hope that some of
you were able to grab. So really, that
public awareness, raising awareness
around stigma issues. We’re doing a
storytelling campaign, helping to spread the word. CDC has really
storytelling segments that they’ve already developed,
doing family education, working with family
members of folks who are impacted by opioids. And that might be
through REVIVE! training for
administering Narcan, how do you family members know
how to help support loved ones and be able to provide
overdose reversal in the case of an emergency. And then looking for expanded
treatment options to help serve the uninsured. And we do– are going to
be doing regular REVIVE! train the trainers here
through Region Ten. So lastly, I just wanted to
share an information referral resource for the community. This is the Help Happens
Here campaign and website. And so there’s a 24– it’s not a 24 hour line, but
it’s staffed nine to four by trained navigators that
can help providers as well as community members
identify local resources. There’s an MAT,
medication-assisted treatment finder resource on there as well
so that if you have patients who are from out of the area
and don’t know local resources, there’s– SAMHSA has a
website to help find medication-assisted treatment
providers in other communities. So that’s all I have. Thank you. [APPLAUSE] MARCIA DAY CHILDRESS: Thank you
to our quartet of presenters. We really appreciate that. And since Secretary Hazel
started that call and response and and we were all
talking about how we all have a stake in this,
now’s the time for you to ask questions,
offer comments, carry on the conversation
at this point. We have a couple of mikes. Please identify yourself when
we bring the mike to you. And we’ll get started. Thank you all. This was a fantastic
presentation. I’m Peggy Plews-Ogan and
I’m a primary care doctor. And one of the frustrations, I
think probably Mo would agree, in treating patients who are
either uninsured or insured is getting
non-medication therapies. And think if we had those
available for patients, many people would never
actually go down this road. And if they were down the road,
we would have an alternative. Any thoughts on that,
Secretary Hazel. WILLIAM HAZEL JR.: I agree. [LAUGHTER] I’ll do one more. AUDIENCE: Yeah. [LAUGHTER] WILLIAM HAZEL JR.: So what we’ve
tried to do with the Medicaid program is to model what we
should be doing to the extent that we can. And I get asked
frequently, well, why don’t we pay for yoga
and things like that? And this comes into sort of a
challenge for us is if we were going to do that, how do
we determine who gets it, who doesn’t? We were talking
before this meeting about evidence-based policy. And we can say, yes, there’s
an evidence-based policy that something works. But suppose now I
had 50 providers for this evidence-based policy. Are they all effective? Are they all above average? How do we know? Do we have to then set
criteria and regulate an industry that will be paid
under those circumstances? These are all pieces that we,
frankly are still very early, I think, in trying to sort out
in the pain management world. Then it gets you to the next
question about insurance coverage and the private world. And think about this,
suppose you’re Anthem now and you say, all right, there’s
this need that we want to meet, but do we want to
be the first insurer to offer all of this stuff? Because that means all of these
people with all these problems will come to us and our
risk profile will soar. Think about that for a minute. It’s just– and we’ll just be
like the UVA of the insurance industry, right? Our risk profile is just gone. And so, so then that comes in. So do we need to make it a man– mandated benefit for
health insurance? And of course, that adds
to everyone’s expense for insurance when you’re seeing
what’s happening in Washington. So it certainly is something
that we’re thinking through. I’m not sure I know the
way there yet, but long and short of it is I agree. [LAUGHTER] AUDIENCE: [INAUDIBLE] AUDIENCE: Hi, Kim [INAUDIBLE]
from the UMA clinic. I work with Mo Nadkarni and
Peggy Plews-Ogan [INAUDIBLE]—- WILLIAM HAZEL JR.:
Keep working with him. He needs the help. MOHAN NADKARNI: Bless you. AUDIENCE: Well, I
have one question though is with the
70% of patients that are uninsured that had
substance use disorders, what are we doing for them? WILLIAM HAZEL JR.:
That’s a good question. I don’t think there’d
be any surprise here that I’ve been an advocate
for expanding Medicaid. The problem with the ARTS is
that 90% of the people who need it don’t have it. That’s the problem. And it is in the
realm of politics. This is politics right now. And you see what’s
going on in Washington. I hoped that we would find out
that Medicaid expansion was here to stay and
we would go ahead and get it done in Virginia. I think the next alternative
to that– a couple of years ago when we were looking at
potentially what do we do, we had some money that had been
appropriated that we decided to use for mental illness. And that’s the GAP
program I referenced in slide which is medications,
labs, and doctor visits for people with mental health. I think there– we could– if they won’t expand Medicaid,
I think one of our options is to increase the number of
diagnoses that fit the GAP. That coverage went up 100%
of the federal poverty level effective October 1. So you’re currently seeing
the beginning of that. But if we can add
in the diagnosis, the primary diagnosis
of addiction, that would be a step. And I think we need
to perhaps broaden– that we have definitions
in the sphere of persistent mental illness
that qualifies people for that. I think we can–
we can add to those to get– to cover more folks. And that would be the
incremental next step, I think, that’s most logical. MOHAN NADKARNI: And if
I can just chime in, the last time I tended on the
wards, general medicine wards, I would say about 45%
to 55% of the patients had some– some illness related
to substance use disorder. And if we– if we think that
we’re saving money by not treating uninsured patients and
letting get into the hospital where we’ve got to totally– WILLIAM HAZEL JR.: Mo, who pays? MOHAN NADKARNI: We all do. WILLIAM HAZEL JR.: OK, OK, good. MOHAN NADKARNI: So figuring
out that I think is huge. WILLIAM HAZEL JR.: I’m
trying to be funny with it. If you don’t try to make
some fun along this, it gets awfully depressing. But the truth is, society pays. We pay it in human cost and
we pay for it fiscal cost. And at some point, I can’t
explain it to legislators. It needs more people than me
to explain to legislators. But we can’t win against this. It’s not going to be quick
no matter what we do. But we’ve got to recognize
the value equation for this treatment,
the $700 a month. It’s not against nothing. It’s against the cost
that we’re incurring in law enforcement, in jails,
in neonatal abstinence, in family disruption,
in infectious diseases, and the list goes on and on. MARNY BENTLEY: And I will
say, just for Region Ten– AUDIENCE: Here’s a mike. MARNY BENTLEY: –we do serve
those that are uninsured. The only program that’s not
open to them is the MAT, but we do serve them
in a sliding fee scale for all of our
non-medication related services so that there is
services for them. AUDIENCE: Hi, my name
is Gabrielle Marzani. Thank you very much
for that presentation. I will tell you, I was
actually trained by Mo Nadkarni and Peggy Plews-Ogan. I did internal medicine– WILLIAM HAZEL JR.:
There’s still hope. Don’t worry. [LAUGHTER] AUDIENCE: –as
well as Region Ten. I’m an HIV psychiatrist. And I’ve been an HIV
psychiatrist since 1999. One of the things that I
have noticed recently is that a number of my patients
cannot be on suboxone because they’re on
too much methadone. Down So, you know, you
can only go on suboxone if you’re on less than 30
milligrams of methadone. And one of the things
I sort of thought about was the fact that there
was just a group of people who will never meet
that– sort of will not be able to go into suboxone. One of the other things
I was thinking about is the fact that there’s
so many patients who have so much anxiety about pain. And in fact, there’s something
called the pain catastrophe scale that Jim Reagan, who
is one of our pharmacists here taught us about, and that
you can actually sometimes predict who’s going to
use or abuse medicine based on that scale. And one of the things
I was thinking about is sort of finding ways to reach
out to patients in the same way that we’re doing telemedicine
with different apps. You know, we have something
called Positive Links which is an app that’s use to
access for patients with HIV to be able to communicate
with each other. And I was just
wondering if there any sort of internet-based
or app-based systems that are being explored in
Virginia or somewhere else. WILLIAM HAZEL JR.: So the
second question first, I’m not sure about
the app-based systems. I mean, there are all kinds
of apps for everything. But being of a certain age,
I’m not as big into– familiar with all of the apps
as other people are. With that, we just had
a hackathon recently to try to bring in teams
from various universities– UVA participated– to develop
apps that would be useful. But we can check that out. The Subutex question
is interesting . When we were faced last
year with legislation that would put the prescription
regulations for Subutex, suboxone, pain
management in code– when things are in code,
that means the police come to your door, and if you break
the law, you get arrested. We didn’t– and code
is very hard to change. Ask Sally Barber here. Getting code changed
is really hard. So we sort of made a
deal with the legislature that we were going to be
very aggressive in creating regulations that
the board manages. Now, the good news about being
under the board of medicine, there’s a recognition
that there are exceptions If you document
what you’re doing, you’ll be OK, right? And the board is
complaint-driven. So we won’t know– I hear a lot judges
say, well, we know this guy is out
there selling the stuff, why didn’t you report him? And then we can do something. Well, it has to
have a complaint. So you need to get the
complaint in the system. And what’s interesting is we
went through a couple of months of open public hearing. And not one person mentioned
a Subutex allergy or anything like that. As soon as the regs went
on like February 22, we had a flood of mail
about the allergies. It was like a new disease
was invented in the time that regulation went in. It’s amazing how that happened. So we went back and
we looked through. And it was changed. And there’s looking
at what we would think a percentage
of patients who have to have that product would be. But remember, the goal is, if
you and your medical opinion think you need it and you
can document and you’re OK. It’s good practice of medicine. It’s in statute. And that’s really what
we were trying to avoid. And that will evolve as
the science involves. MARCIA DAY CHILDRESS: I’m afraid
our hour has evolved and come to an end. But please join me,
again, in thanking Secretary Hazel, Dr. Mo
Nadkarni, Marny Bentley, Rebecca Kendall. [APPLAUSE]

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