Articles, Blog

Addressing the Opioid Epidemic with Patient-Centered Research

December 17, 2019

Good. Good morning everyone. Really. Welcome to the PCORI annual
meeting. Christine Goertz I’m the vice
chair of the PCORI board and have the honor of being the
chair of this this really important session this morning
as as you all know our country is facing a unprecedented crisis
with opioids. There are a lot of ways to to
look at at that crisis and and because he has a full portfolio
of approximately one hundred million dollars looking at that
last year we focused on non-farm illogical treatments for for
pain and how it might help address the opioid crisis and
this year we’re looking more at ADD medication assisted
treatment and in other related therapies. So we really appreciate your
time in an interest in it. In addition to being on the
board of governors my my day job is I have a 25 year career doing
patient centered comparative effectiveness research primarily
looking at non-farm illogical treatments for for chronic pain
I’m the chief executive officer of of a nonprofit called the
Spine Institute for quality. And I’m currently conducting
several NIH and diodes funded study comparative effectiveness
trials. Again looking at conservative
treatments for four chronic and acute low back pain it is my
pleasure. What I’m going to be doing here
is each. Each speaker as they as they
come up are is going to be loading their their slides and
so I’m going to introduce each person while they’re while
they’re loading there their slides and and our our first our
first speaker today is my co-chair and Dr. L’s huts
Mueller who is an associate director of health care delivery
and disparities program here at PCORI. Prior to joining PCORI she was
managing editor of health technology assessments at haze
Inc. And before that she was an
associate professor in the department of psychiatry at
Johns Hopkins University School of Medicine where she served as
principal investigator on several research grants and
directed at human subjects research laboratory folks and
drugs of abuse and addiction including opioids. Her work has been published in
numerous peer reviewed papers book chapters and helped
technology assessments Pecora. She is also in charge of several
PCORI funding announcements focused on treatment of opioid
use disorder. She also serves as chair of an
IAB for a small research group in Baltimore. Welcome. LS So how is everyone enjoying
the meeting so far. Good good. One add that we are we’re having
the speakers present on this panel. But then what at the end we’ll
also have two discussions and we will. And then we’ll be opening it up
for questions and and we’re liberally looking forward to
hearing what all of you have to say as we’re during that
discussion portion of this session. Somebody told me not too long
ago that you know it used to be that the the most common lie in
the world was the check was mailed yesterday and now it’s
this was just working a minute ago I swear that we thought her
slides were loaded and they were just working a minute ago. All right I think we’re ready to
go ahead and get started. It’s now thank you and thank you
Christine. Thank you all for being here. I don’t need to repeat anything
about the incredible importance of this topic given the opioid
epidemic and the many many challenges it fit we face with
it. If this works I have nothing to
disclose. What I want to do is just very
briefly give you an overview of the PCORI portfolio in the area
of opioids. And we really have thought about
it in a number of ways addressing it from different
angles and that’s what I want to briefly show you. So as of actually yesterday
October PCORI has awarded 88 million dollars to fund 16
comparative effectiveness studies and there are
approximately one hundred and seventy thousand patients
involved in these studies. Now this includes active
participants in research studies who are having visits and being
tracked but also patients who have consented to have their
administrative health data used in research. So when we started funding
opioid studies we really wanted to make sure that we addressed
the research needs in across the whole care continuum. And so that includes prevention
of unsafe prescribing alternative treatments non
opioid treatment options for pain because we all know by now
I think that some part a large part of this epidemic resulted
from well intentioned prescriptions of opioids for
pain. Also the management of long term
prescription opioid use. And finally the treatment of
opioid use disorder. So this just lists the number of
targeted funding announcements that we’ve put out in the past
couple of years. We started with strategies to
prevent unsafe opioid prescribing in primary care. That was focused primarily on
patients who had not yet been prescribed opioids. We then had a funding
announcement for clinical strategies for managing and
reducing long term opioid use for chronic pain. So for those patients who have
been taking opioids and and are often on high doses and in the
last two years as Christine also mentioned we have really focused
on treatment of opioid use disorder. We had one funding announcement
that focus specifically on pregnant women and their
infants. And then the most recent one
that was released this year focuses on co-operative
effectiveness of different psychosocial interventions that
are part of medication assisted treatment so I want to just give
you a sense of of the number of studies and that we focused in
these of the what happened in each of these areas. So the first one is prevention
of unsafe prescribing. And we have I’ve listed here and
I don’t expect you to read through every title of every
study that we funded in this area but I just want to give you
a a sense of the studies that are currently funded and
producing results in this area. So they include naturalistic
experiments. They include interventions
focused on provider behavior and also interventions focused on
patient behavior the next sort of bucket that we think about in
terms of funding studies is the non opioid treatment options for
pain. And in that one we have funded a
number of studies and the ones we actually have a lot more
studies that that address pain. But the ones that address pain
in patients that are receiving or would otherwise receive
opioids are listed here and the first study I do want you to
take a look at. Because we have as a speaker the
P.I. on that study Beth Stern all who is here and she will be
speaking about her study that has a component that is the
comparative effectiveness of cognitive behavioral therapy
comparing that to chronic pain self-management. But the aspect that she’s going
to talk about specifically today is the context in which these
interventions are being compared. Which is opioid reduction for
patients. The third bucket is the
management of long term prescription opioid use. So those are the patients who
have been taking up prescription opioids for pain. And here you see a list of the
different studies that we funded in that area. And the one that I would like
you to pay particular attention to today is a study looking at
prescription opioid management a chronic pain patients that
looked at a patient centered activation intervention because
ah one of our speakers today Monique does is going to talk
about the patient activation and patient engagement parts of that
study. Finally the treatments for
opioid use disorder. We funded a number of studies
some of them are the top bottom two here are focused on pregnant
women but deep but the first three are really focused on
different populations. The first one is prisoners who
are getting released from from prison. So before reentry they are
treated the second one is a is a one that I would like you to
base for particular attention to again because we have David
Guest friend here we’ll talk about the trial that he is
running that looks at offering medication assisted treatment
and a number of psychosocial interventions in effect UHC
specifically and that was. So that gives you a quick broad
overview of the Byrd folio and without saying anything more I
want to give the floor to our actual investigators Great. Thank you. Thank you very much. As soon as she uploads her
slides I’d like to introduce the first of our three panelists Dr.
Beth Darnell. So Dr. Darnell is a principal
investigator for national pain and opioid reduction research
projects with a collective funding of 13 million dollars. Her work focuses on developing
investigating and disseminating scalable and effective
treatments to reduce pain and opioid use. In 2018 the journals
disseminating scale of community based patients and opioid
tapering research was published in JAMA Internal Medicine and
received a National Research Award. She leads a PCORI funded study
uncompassionate patient centered opioid tip tapering and
comparative effectiveness of self-management and
psychological treatment for chronic pain. No now has authored three books
and spoke on the psychology of pain relief at the 2013 World
Economic Forum. She has also been featured in
Scientific American The Washington Post on BBC radio and
in nature. Welcome Dr. Arnall. Thank you. Thank you so much. And good morning to everyone. So these are my disclosures my
funding both from PCORI and from the NIH as well as some
consulting. As was mentioned I have authored
books for patients also for clinicians and am focused on
training health care clinicians about how to best treat pain. I’ll move through this very
quickly in a fortuitous stroke of luck and fortune. My op ed on patient centered
ness as a critical pathway to address the dual crises of pain
and opioids published last night in the hill and I just wanted to
give a public shout out to Christine’s stencil for her
support and assistance with getting this out. This is a very timely topic. As you all know the most recent
data suggest that up to 100 million Americans are living
with ongoing pain of some type. This is roughly one in three
individuals and this is true worldwide. Now pain touches all of our
lives many of us in this room probably are living with pain
but if you are not personally you probably have a family
member or loved one who does. We want to focus on how we’re
treating pain historically over the past 15 years that has been
over focus on prescribing opioids to treat pain such that
currently roughly five and a half percent of the U.S.
population or almost 18 million Americans are taking long term
prescription opioids right now. And this is problematic. Although some people definitely
need prescription opioids to be one part of their care plan this
over emphasis has conferred risks to certain patients. And you’ve all heard about
mortality related to prescription opioids. While this is largely fueled by
illicit opioid use this has conferred risks and even
mortality to patients who are taking their opioids their
medically prescribed opioids. So the question is how do we
treat pain best and how do we help keep our patients safe. So there’s been an increasing
focus on non pharmacological pathways to address pain and
also as a pathway to mitigate this over focus on prescription
opioids. Now it’s not just about opioids
or no opioids. This binary reductive focus. Ultimately we want to help our
patients live better with complex medical conditions with
the pain that they have. And this is really where the
rubber meets the road. Now multiple national agencies
such as the Institute of Medicine at NIH the CDC have an
even PCORI have called for the better integration of evidence
based psychological and self-management strategies as a
pathway to help people better manage pain and ideally reduce
reliance on a purely pill based approach. Now this dovetails with what we
know about how pain is best treated using a bio psychosocial
treatment approach. And this is really at the core
of patient centered ness where we’re fundamentally treating the
person who has pain not just the reductive symptom of pain but
this hasn’t always been the case even though we’ve known that the
bio psychosocial model of pain treatment is superior. We have over the past decades
been overly focused on a biomedical approach that fails
to both characterize and attend to the individual needs of each
patient. When we take a look at the
actual definition of pain what we see is that there is the
person in the definition. Since the definition from the
International Association for the Study of Pain pain is
defined as both a negative sensory and emotional experience
it’s fundamentally a psychosocial experience or
psycho sensory experience that includes the psychology of the
individual. But we don’t often treated that
way again. We tend to emphasize a
biomedical reductive model that actually supports prescribing as
the main emphasis. If we think about pain I like to
describe pain as our harm alarm it’s designed to get our
attention to alert us that there is danger or a threat that is
afoot and that we must attend to it and it motivates us to escape
whatever is causing the pain because that’s a potential
threat to our survival. And it works really well if you
place your hand on a hot stove. You’re going to feel that
sensation you’re going to be motivated and prepared to escape
the cause of the pain. But what happens when we have
migraines or fibromyalgia or ongoing low back pain or sickle
cell disease pain or any of the numerous pain conditions that
people are living with today. Real world patients when that
harm alarm rings and that motivation to escape pain comes
into play you can’t readily escape pain that’s coming from
inside of you. And so this creates a tension
and it creates a lot of distress for people who are living with
pain because we’re all born with the motivation to escape pain
but we are not born with the understanding of how to modulate
pain the distress that it causes us and how it alters our lives. But this can be learned and this
is really the realm of pain psychology and self-management
where we teach individuals information and skills so that
they become equipped to best manage their own pain and
symptoms not necessarily to the exclusion of medication but this
is critical foundational information that helps them live
better. So cognitive behavioral therapy
for pain is typically comprised of a whole host of different
topics and skills that patients acquire over the course of up to
eight weeks of treatment. And this is true for the chronic
pain self-management program to which uses really applies. Many of these same principles
and information but the chronic pain self-management program is
typically delivered by two trained peers people with lived
experience whereas CBT is typically delivered by
psychologists. So now what we want to do is
take what we know about these evidence based treatments for
pain and begin to think about how we can apply them to
facilitate opioid reduction. Now this is a topic that’s
fraught with complications and fears if you ask patients what’s
their number one concern about reducing their opioids. They’re going to say pain if
they’re worried about having pain and that’s a legitimate
concern. They’re also concerned about
having withdrawal symptoms. I’m talking about people who are
taking daily prescribed opioids and some of this fear is borne
from personal experience because if you’re taking opioids
regularly on a daily basis if you miss a dose of medication or
you forgot your prescription at home or maybe you tried to taper
your opioids on your own and and stopped the medication too
quickly you’re going to experience withdrawal symptoms
including increased pain. But when we take a look at the
data around opioid reduction we see that when opioids are
reduced the right way that pain doesn’t actually increase. In fact pain improves on
average. Now this isn’t to say everybody
will have reductions in pain but on average pain improves with
opioid reduction. But the key here is that they’re
being reduced the right way in costly inpatient programs. So the question is how do we
scale a program for community based outpatients. Because almost none of the
patients that we know are going to be able to access these
costly inpatient programs. So as a prequel to My funded
PCORI project we conducted a study in community outpatients
taking prescription opioids and invited them to participate in a
patient centered opioid tapering program. This was voluntary and we did
not. We did not request that patients
taper to zero. Rather we asked them to partner
with their doctor and reduce their opioids to the lowest
comfortable dose over a four month study period. We invited one hundred and ten
patients to participate. Sixty eight accepted and fifty
one completed our program. There was only one variable that
distinguished complete hours from complete hours and that was
depression. So these are the variables. This is our sample cares
characteristics you can see that people have been on opioids six
years and the median the morphine equivalent daily dose
was almost 300 milligrams. This is a real world sample and
what we found was that over the course of the four month study
period people cut their opioid doses by about in half. And here are the actual data
each point is an individual patient. And what you can see is that the
initial opioid dose did not predict taper response which
means that our data suggests that we have a formula that can
help patients that are even on high dose opioids. And here’s the really important
slide their pain did not increase. On average you see a couple of
dots up there and that really stands as a testament to our
need to be patient centered in the application of these
approaches. But if you look at the data as
an absolute change in morphine equivalent pain actually
improved as people reduced their opioids. But again we want to help people
live better not just reduce their opioids. And this is the comparative
effectiveness study that we are conducting right now. This is funded by Pecora. This is the Empower study
effective management of pain and opioid free ways to enhance
relief the logo and the branding of this study were was created
and supported by patient advisors. We are studying almost fourteen
hundred patients taking long term opioids for chronic pain in
four states seven different clinics and we are carefully
selecting the patients who enter our study to make sure that this
tapering program is right for them and we monitor them very
closely to make sure we are attending to any discomfort and
symptoms that may arise. Everybody who comes into our
study engages in a voluntary patient centered opioid tapering
program and then they’re randomized to either eight weeks
of CBT six weeks of the chronic pain self-management program or
just the taper only. And we hypothesize that these
behavioral pain medicine classes will optimize patient response
to the taper. I want to emphasize that a
critical portion of our study is training physicians and in how
to partner with their patients in a patient centered way. This is a pragmatic study which
means that we’re going into seven different clinics and
we’re fundamentally altering clinical care and then we’re
studying the results of that so really paying close attention to
the doctor patient relationship and equipping physicians and
prescribers with the skills to conduct patient centered pain
medicine and opioid reduction is a critical element. So I just wanted to mention our
study is now lives. You can go to the Empower. You can go to empower dot
Stanford dot you if you’d like to see our Web site. We utilize the voices of
patients with successful lived experience with opioid tapering
as a critical element of engaging patients their interest
and their willingness to join the Empower study. I just want to give a shout out
to all my colleagues and collaborators that I work with. Here is the study website. If you have an interest in
learning more. And with that I will say thank
you for your attention. Right. Thank you. I’m going to invite our next
speaker to go up in and load her slides. Ms Monique does has more than 20
years of experience imagining managing multi site
observational studies behavioral interventions and clinical
trials. Her current research interests
include chronic pain prescription opioids use patient
reported outcomes and medical medical cannabis use. She currently manages studies on
opioid use and addiction at Kaiser Permanente north northern
California’s Division of research including a recently
completed PCORI study of a behavioral intervention in
primary care for patients on long term prescription opioids. Her own experience with chronic
pain and her positive experience with patient partners has led
her to her sustained commitment and patient centred research. Welcome. Thank you. First I just want to say I’m
very honored to be here being involved with this because study
has really changed my life and I have had a positive experience
positive impact on the work that I do and my own personal life. So thank you of course to the
panel who the PCORI staff who put together the panel. So I’m a project manager at
Kaiser in Northern California in the division of research and I’m
gonna talk a little bit about a study as Elyse mentioned. This is one of those as a PCORI
study that has been funded. The studies were finished with
data collection and I’ll talk a little bit about some of our
results. I have nothing to disclose for
those of you who are who are trying to get continuing
education credits. I hope that by the end of the
session you’ll be able to talk about how one factory funded
study addressed the needs for patient centred research when
treating chronic pain in primary care. Thank you Beth for such a
wonderful overview of the opioid epidemic in the United States
and the prescribing and some of the patient centred work that
you’re doing it was really wonderful. I’m I won’t talk too much about
it but I will say that as we can see opioid prescriptions are
declining nationally and despite that there’s still a lot of
concern over the high rates of abuse and overdose. And there’s a lot of efforts to
combat this. And one or local initiatives in
health systems and Kaiser is actually one of those an
interesting sort of side note is that as we were beginning our
study at the height of the epidemic in 2015 Kaiser had
rolled out a big safety initiative which had some
interesting challenges for the implementation of our study. In addition the CDC put out
guidelines in 2016 that had an impact. And as you can see by this
recent paper by Amy bone heart there was just published last
month. The results are coming in to
show that the 2016 CDC guidelines are affecting opioid
prescribing rates high dose rates co prescribing with Ben
those Dias opioids all these rates are going down. And I wanted to highlight here
in this paper in yellow that the outcomes that they measured now
although that declining rates of opioid use are excellent for
population health and policy. What did they say about the
patient perspective and how does that affect patients. Does declining opioid use
necessarily good for the patients themselves. As Beth Ann indicated a lot of
patients you know use opioids and need opioids to manage their
pain. The people in our study on
average were living with chronic pain for over 15 years. So this is a substantial impact
on one’s life quality. So I’m looking forward to seeing
more studies that come out that show the effect on patients and
patient centered outcomes on some of these initiatives. Now I’m going to turn to some of
the evidence gaps that were that we were facing five years ago
and keep in mind this study that we were we. We were designing it five years
ago. So what might have been an
evidence cap then might not necessarily be one now. But we were really interested in
looking at primary care and we were noticing that there was a
need for evidence based research on patient centered approaches
for treating chronic pain in primary care and why primary
care. Mostly because the majority of
prescriptions for opioids aren’t come from primary care primary
care doctors and a lot of patients have an established
relationship with their primary care doctor. So it’s a good starting point to
have to have a dialogue to learn how to speak to your physician
about your health care needs and your pain and your opioid use. And we found that a lot of
patients didn’t necessarily want to go to a multidisciplinary
pain program. They didn’t need one. There was stigma involved with
that and some in some health care systems. So we decided to focus on
primary care and we also decided to look at some of the
self-management and education movements that were going on in
other chronic health conditions. For example diabetes and heart
disease there’s a lot of movement towards engaging
patients to take their own health care into their
consideration. And so we wanted to see if we
could apply that into the world of chronic pain and lastly we
were interested in bringing the patient activation paradigm into
the world of chronic pain and opioid prescribing. And we based some of this work
on a study that we did of the Division of Research called the
linkage study which was based in substance abuse treatment and it
was an activation intervention that was six sessions designed
at activating patients to get them to become more involved in
their own health care. And it was based on Judith’s
Hubbard’s work and the direct definition that she uses of
patient activation is understanding one’s role in the
health care process and having the knowledge and the skills to
manage one’s own health. And so this was something that
we were really interested in looking at just activating
patients to become more involved in their health care around
their pain and their opioid use. Would it improve outcomes so
I’ll talk a little bit about now about our study. Call the Activate study. And again it was a patient
centered activation intervention. Faced in both in primary care
the principal investigator on the study was Cynthia Campbell. It was a randomized pragmatic
trial and pragmatic in the sense that we implemented in a primary
care setting in a real world setting. We had very little exclusion
criteria other than being on opioids for three months. We randomized and 376 patients
into a usual care arm and a behavioral intervention. And in addition to electronic
health records we looked at we’d collected data via surveys at
baseline six months and twelve months. Now the intervention itself was
brief. It was for 90 minutes sessions. And the goal of the
interventions was to empower patients to take more an active
role in their not only their pain management but their
overall health. And the sessions were led by a
psychologist a pain psychologist and were designed with input
from patients excuse me the sessions focused on three main
things. One was non pharmacological
strategies for managing pain. So this was sort of a brief
introduction to chiropractor acupuncture massage and we had
it some hands on activities and the interventions that were very
engaging for the patients like we did guided imagery and we did
mindfulness activities. We also focused on teaching
people about the online resources. Kaiser is really well known for
its online portal called KP dot org and we had a lot of evidence
to show that people were using KP dawg but they weren’t
necessarily using it to its full capacity. So we did hands on activities
where we showed people how to track their lab results and
email their doctors and schedule appointments and things like
that as well as showed them a wealth of online resources on
health and wellness and we also focused on communication skills
as you can imagine these are there a lot of difficult
conversations that have to happen between a patient who is
living with chronic pain on opioids especially in this very
stigmatized environment. So I just wanted to point out
here again that the goal of the intervention wasn’t necessarily
to test self-management of care or to look at any particular
thing it was to try to see if we could activate patients and
intervene upstream in primary care to get together to get
patients to be more involved in their health care. Real quick a mention of our
study team in addition to our eleven clinical stakeholders
that we had we had five patients that were involved in the study
and we recruited them very early on from pain programs throughout
California. And it was very very important
part of our study designed to have this patient input from the
very beginning. And here you could see their
pictures. And it was particularly
important because of the stigma and the marginalization to
constantly have their input on every phase of the study. And here you could see we just
that we had them involved in the early concept of the study from
recruitment activities to data collection all the way through
dissemination. I do want to point out that one
thing that we did that was a little unusual at the time is
that we involved patients in the data analysis phase and we
thought this was really important as because we wanted
them to be involved through the life of the project and often
there’s a drop off with patient engagement towards the end
phases of a study because it is hard to engage people with
different education levels and different experiences. So we did a series of eight data
lessons with our patients learning teaching them about
statistical modeling and all sorts of things that would
enable them to feel more comfortable. And this was a very worthwhile
and enriching experience for everyone that I’m happy to speak
with more. The end with anybody who’s
interested. So a little bit about our
results again we randomized three hundred and seventy six
patients and we looked at outcomes at six months and
twelve months. And although we did see a
decline overall in pain severity and opioid use over the course
of the study we didn’t see a significant difference in those
two outcomes between the two arms between the usual care arm
and the intervention arm. However we did note with regard
to some important patient centred outcomes we did note
that the patients participants in the intervention did have
overall higher health scores lower depression scores and
higher function scores and by function I mean the ability to
engage in your normal activities social activities climbing
scares going to grocery shopping things like this and these
outcomes a lot of them will use the promised measures but these
were all outcomes that were developed by our patients as
being patient centered as to what really mattered to the
patients. So of course pain is important
but also what matters is the ability to live your daily life
in addition we also noted an increase on use of the online
portal particularly with the health and wellness resources
available and an increased use of self-management skills
particularly mindfulness mindfulness and meditation. So in summary what we showed was
that an increase there was as a result of the intervention and
participation in the intervention there was an
increased self care and a greater engagement with the
health care system. And so even despite the limited
intervention and being in an integrated health system we’re
optimistic that even this small intervention could help engage
people in their own in their own health care and managing their
own pain and many many study participants saw this experience
as a stepping stone. Here’s one quote from one of our
participants that said I’m going to ask my doctor to refer me to
the pain program that he’s been trying to get me to go to for
years. I’m thinking of these four weeks
as a steppingstone. And so lastly in addition to
empowering the participants in our study the experience of
being in the study empowered the patient partners. Some of them have gone onto and
be engaged in more patient centered research after the
study ended and some of the curriculum that has also been
adopted by some of our clinical stakeholders in the Kaiser
system. So a quick shout out to all the
researchers and all the collaborators and the patient
partners. And lastly we are one of the
studies that have wound down and gone through the whole cycle of
PCORI through our peer review and that last last week our
research summary was published on the PCORI website. So thank you very much. Thank you. All right. Our next speaker our final
panelist is Dr David Gast friend whose addictions psychiatrist
and principal investigator of the PCORI funded path study at
Harvard. He directed Massachusetts
General Hospital’s addiction research program. His American Society of
Addiction Medicine or ACM criteria research contributed to
endorsement by most states. His one hundred and fifty
publications include the ASEM criteria and addiction treatment
matching and his continuum a sum criteria decision engine is
being adopted nationwide. His co fund co-founded dynamic
hair health a technology for contingency management one
Harvard’s Business School’s new venture competition global grand
prize. Served as a consultant to
governments in Belgium China Iceland Israel Norway Russia and
the United States. Welcome. Thank you very much. When we look at the patients who
have not been able to diminish their opioid consumption and who
end up with an opioid use disorder we see a very diverse
population and the treatments available to them are still way
too limited and the utilization is way too low and that is
fostering a persistence of the epidemic even while prescribing
has started to come under control. So the current practice is
specialty counseling and community addiction treatment
programs with detoxification from the opioids. There is a rising utilization of
opioid based medication treatments Oh bot. But the absence model remains
dominant and the problem with that is it’s not the most
effective approach. There is increase in
motivational enhancement therapy utilization which is a patient
centered approach but even that is limited in its efficacy. In this population in the
absence of integration with medication the American Society
of Addiction Medicine publishes criteria that says you need to
have multi-dimensional assessment because so many
different domains of need occur in this population and need to
be cared for in an integrated fashion so they specify six
dimensions of withdrawal by medical problems psychological
problems problems with readiness relapse potential and
environmental needs. But by and large the field of
addiction treatment is aware of these criteria but not yet
really using them in any systematic fashion. And their point is to use the
least intensive resources known to yield optimal outcomes which
is both respectful of patients needs for effective treatment
but also resource limitations. So my colleagues at public
health management corporation in Philadelphia Dr. Adam Brooks
who’s here in the room conceptualized a personalized
addiction treatment to health model. This was years ago about five
years ago now and we were funded by Pickering with a large
pragmatic study to randomize 800 patients comparing the path
model to the community standard specialty addiction programs and
we decided to invoke a number of evidence based treatments and
I’ve organized them here according to the vectors of a
public health epidemic which starts with the agent. It’s not a virus or bacterium as
a typical epidemic. It’s the drugs of abuse heroin
fentanyl now and they’re conveners. So what modalities are evidence
based for addressing the problems of the agent. Well we have several FDA
approved medication assisted treatments m80 the agonist
methadone is well-established for decades now. Partial agonist treatment with
buprenorphine and there different formulations sub
lingual and extended release month long and six month long
implants. And although this is newer there
is a very solid evidence base for improvement in reducing
overdose and death. We now have an antagonist
approach Naltrexone which can be administered not as a daily oral
medication which produces very poor adherence but a extended
release injection that lasts for a month and two. Comparative effectiveness trials
head to head between extended naltrexone and buprenorphine
show that you get very similar outcomes if the patient success
succeeds in starting on the medication contingency
management is a very different approach but it essentially is a
physiologic response approach. It actually pays patients money
for adherence and retention and abstinence and that addresses
not the cortex of the brain the outer brain here. But if you see in the host model
of the brain that pink region which is representing the reward
center so contingency management works at a level below
consciousness directly at the reward centers function. But we also have to address
consciousness and learning and changing behavioral patterns and
cognitive behavioral therapy is a well-established modality in
general although not that effective by itself in addiction
treatment after detoxification. So CBT is being used in
combination with CRM where we see the best results in
literature. Finally the patient’s
interaction with their environment is critical in this
disorder and peer support has a lot of face validity and early
evidence for being effective for that need. So I’ve just listed a whole
bunch of different approaches and they’re available here and
they’re sparsely in the community but in very disparate
locations and that fragmentation is absolutely the worst setup of
service delivery for a disease that disrupts the patient’s
motivation to get well. So 90 percent of people with
opioid use disorder don’t seek care or get it. And the resources are limited
when they want it. The access is is sparse and
their motivation is impaired and society doesn’t understand that
disruption of motivation. The rest of us when we get sick
we seek wellness we hurt. We want to enter the doctor
patient relationship. That’s not the case for somebody
in the throes of addiction and the highly fragmented system
needs to be essentially D fractured. So the path model proposes to do
that path is patient personalized addiction treatment
to health and we are operating it in the study in federally
qualified health centers which have the ability to offer
multi-dimensional assessment and evidence based treatment with
each of these components. So by D fragging the system
invoking the primary care model and offering long term
collaborative care the hypothesis is that we should get
as good or better outcomes than the specialty system but when it
comes time to advising patients and helping them make choices it
turns out to be really tricky in this disorder. For one thing there’s a
tremendous range of variation among patients and their needs. They have different types of
opioids that they use prescription heroin or fentanyl. There are different routes of
administration smoking snorting oral use injection patients with
youth are most common in the epidemic at the moment but the
fastest rising subgroup is the elderly with opioid use disorder
Chronic City an impact on the patient’s level of function is a
big issue. Prior treatment experience and
what phase of recovery is the patient in because that can
change their potential interest and suitability for these
different treatments and their combinations. If the patient has chronic pain
it substantially complicates how we’re going to treat them in
their opioid disorder and it may not be just how much pain they
objectively have but what is their orientation to pain. Are they preoccupied with it or
are they obsessional about it. CO occurring disorders of mood
anxiety psychosis have big impacts on patients ability to
engage in these treatments and what treatments should be
selected. And many patients with these
disorders end up eventually with social chaos and
disenfranchisement. And yet when we offer them
treatments a number of them will say I don’t want to participate
because I’m afraid about discontinuation going off these
some of these medications can involve withdrawal. And I hear that it can be
difficult. So the literature really does
not guide us on selection factors and therefore the best
method or approach for selecting between these medication
approaches methadone buprenorphine or extended
release naltrexone may simply be patient preference based upon
the features the side effects the way these medicines work. And so we need more evidence for
how to guide initiation and how to guide termination decisions
because another problem is adherence and persistence over
time. We know that long term treatment
is most effective but patients don’t tend to stick with these
medicines. So we have different models harm
reduction which is permissive and engaging of as many patients
at the moment that they are ready to talk as possible versus
the recovery model which is constraining and sets firm
expectations for treatment participation and performance in
terms of abstinence scheduled treatment versus flexible
approaches. And how do you design a study
that’s going to offer flexible patient centered approaches and
yet not standardize what’s being delivered. How do you do statistical
comparisons when you have that model. Yet the best best basis seems to
be patient preference for what we know now. We have completed a pilot phase
of this study and in the four F2 H C’s where we’ve operated the
study we have some substantial learnings and there they’re
challenging. One thing we find is that many
buprenorphine wavered prescribers in this country who
have the legal authority to prescribe this federally
controlled substance don’t prescribe. In fact more people who have the
waiver don’t prescribe than are willing to prescribe an
induction for Naltrexone is limited. There are protocols but they’re
not being used group therapy and peer specialists are essential
ingredients to successful outcome but they’re not
reimbursed in many of the FDA UHC systems contingency
management has federal HHS Office of the inspector general
policy obstacles. We are working on solutions for
those but they have inhibited our ability to get these studies
started. Primary care tends to have
behavioral care and is focused on short term. But we need to have a long term
focus for this disease. And one thing I will say that I
thank the Corey for its influence on consumer input peer
mediated street recruitment was recommended by our community
advisory board and my co investigator Andre Reid and has
doubled the rate of recruitment. So that’s a very impressive
outcome of introducing their input. There’s a lot of opportunity for
impact if Coates sees our numbering over thirteen hundred
in the country one in 12 Americans has access to enough
to see if we can show better outcomes with the path model and
F2 HD or even similar outcomes similar outcomes would be great
because then we could dramatically increase access to
care and that’s the goal of this study. Thank you. Applause Thank you very much. Thanks to all of our panelists. So now we’re going to turn the
podium or the mikes over to our are to discuss who I will
introduce them both at the same time and you’re welcome to
either remain seated or give your your mark set at the
podium. It’s our first discussion is Dr.
David Kelly who oversees the clinical and quality aspects of
Pennsylvania’s medical assistance programs which
provide health benefits to more than 2.5 million recipients. The Office of Medical Assistance
Programs recent accomplishments include participating in a multi
payer medical home collaborative initiating pay for performance
programs and developing a multi-state application for the
Medicaid electronic health record incentive program. Previously Kelly was the medical
director responsible for utilization of quality
management in Pennsylvania for Inc. Served as assistant professor
and director of clinical quality improvement at the Pennsylvania
State University’s College of Medicine and practiced in
multiple clinical settings is board certified in internal
medicine and geriatrics our second discuss it is Dr. Travis
Reeder Dr. Reeder is a philosopher by training and a
bioethicist by profession he writes and speaks on a variety
of ethical and policy issues raised by prescription and
illicit opioid use. This interest in opioids came
about suddenly after a motorcycle accident. When reader took too many pills
for too long and suddenly found himself with a profound
dependency. In the wake of that experience
he became driven to discover why the practice of medicine
struggles to deal with prescription opioids and how
that problem is related to the broader drug overdose epidemic. He wrestles with those questions
in several academic and popular publications as well as in an
upcoming book to be published in 2019 with HarperCollins titled
pain in America. Thank you to our discussions. Thank you and I’d like to thank
Corey for inviting me to be part of this panel and part of this
discussion is the chief medical officer for Pennsylvania
Medicaid where we have done Medicaid expansion of over
700000 individuals that previously had no health
insurance. I will say that probably over
150000 of those individuals now have been able to have benefits
that include fairly comprehensive treatment for
opioid use disorder one of the biggest challenges that we face
in Pennsylvania is we have a crisis. 13 Pennsylvanians die every day
of opioid use disorder that to me that is an emergency. And unfortunately what we see
too often is stigma throughout the community. Had the provider level at law
enforcement level at the legislative level. I think we’re starting to see
some decrease in that stigma. But it’s still there what’s
vitally important really is the patient centered approach that
PCORI brings to the table and the research that you’ve heard
about I think is vitally important to our Medicaid
program. I will say that there are some
programs that we’ve tried to do over the last two or three years
to address the opioid crisis. We’ve developed Centers of
Excellence a model where there’s a patient centered person
centered approach where there are we are paying for care
management teams including peer recovery specialists. We also are funding other hub
and spoke models that have been published in other state
Medicaid programs have used. We’re really trying to
disseminate that hub and spoke model. We’re very much so expanding
medication assisted treatment over the last five years we’ve
seen a large increase in the number of individuals that now
take advantage of both methadone buprenorphine as well as
injectable Naltrexone. We’ve seen our numbers go up
significantly. We also have seen a fairly good
duration of treatment for those individuals because we think
that for folks to move towards recovery you really have to stay
on stay in your treatment course and move towards recovery the
patient centered person centered approach is vital because in the
health care delivery model one thinks of our in the context of
medical care and we know that everyone’s lives focuses more
than just the medical system and that social determinants of
health if they’re ignored we’re never going to come up with
great solutions really need to be paying attention to not just
the medical model of care but all of those social determinants
that affect our daily lives. And again Corey’s approach is
very person focused and takes into account all of those other
variables that happen on a daily basis. There are other programs that
we’ve implemented. I’m not going to sit here and
talk about them but I think the most important message I have is
we are in the middle of an opioid crisis. We need to be compassionate. We need to reduce stigma. We need to make sure that
individuals that are on chronic opioids usually no fault of
their own that they need to be treated compassionately. They need to be offered
innovative programs some of which you’ve heard about and
from a Medicaid standpoint at least in Pennsylvania. We’re very open to developing
these new models of care that are very person focused. So thank you very much for the
opportunity to be here and to be able to share my thoughts with
you. Thanks Well if all you heard of
my introduction is that I’m a philosopher. Don’t worry I won’t talk about
any of that with my few minutes today. I’m here mostly as a as a
patient and as a storyteller. So I’ve been doing a lot of
storytelling the last few years ever since I had my motorcycle
accident and the reason I’ve been telling this story is it’s
a strange experience to be inducted into the health care
system as a bioethicist and research faculty at Johns
Hopkins. And it’s a little surreal to
kind of develop all this first personal knowledge of the sorts
of things that you might study in a textbook. So one of the things that I
discovered is that opioid withdrawal is not like it is in
the movies. If you’ve ever seen someone go
through a heroin withdrawal a movie it’s like a clip of
shivering and sweating and then the next clip is the next day
and thank God they’re through that. So I ended up being put on high
and escalating doses of opioids for very good reason. I had my foot blown apart and in
many surgeries to put it back together. But the problem was nobody was
looking out for me. As I got passed through this
very complex system from provider to provider from
hospital to hospital and so at the end of months of this
finally somebody looked at my chart and asked me about my meds
and said whole that’s that’s too many. We need to stop that now. And then the problem was that
nobody knew how to do that. So I really appreciate hearing
people like Beth talk about explicitly like here’s how we
taper because one of the things you find out if you work in work
with clinicians all around in all different settings is that
everyone has this DEA license who allows them that allows them
to prescribe opioids does not then know how to safely get a
patient off of opioids. And one might think that would
be a pretty reasonable principle to adhere to if you can
prescribe something. Make sure you can prescribe it. But that’s not a principle that
has been internalized in medicine. And so a lot of what I do is not
high bioethics. I go around and talk to
clinicians and make that point and say Oh yeah. That’s a really good point. I wonder how we’re gonna do
that. And then there’s the hard
promise of of establishing structures to allow that. So I don’t have in just a couple
of minutes time to give you the gory details but the points that
I want to make. Well and if you want them you
can go to my TED talk. I’ve done the 14 minute version. I tried to make you
excruciatingly uncomfortable by describing what opioid
withdrawal is like. But at the end for me I was in
it for a month because my my prescriber said oh drop a
quarter if your dose each week and in four weeks you’ll be
done. And that is just about like the
worst way to do it. It was an incredibly high
decreased by percentage and by percentage it gets more each
week. So I had terrible withdrawal
that got worse each week but it also lasted a whole month. All right. So it was just about the worst
of both worlds. And at the end of a month I was
actively contemplating suicide because I was in a very very
deep depression. When I came out of this and I
started thinking about it and reflecting on the issue there
was a there was this main idea that you know if you prescribe
opioids you really need to know what to do with them afterwards. But in the context of what we’ve
been hearing so far in about Pickering’s very nice kind of
funding chart I really appreciate ls putting up these
four quadrants. The one kind of point that I
want to leave folks with today is we talk about responsible
prescribing in the context of an opioid epidemic with the
language of we need to decrease opioid prescribing and that’s
multiply problematic because decreasing isn’t a good goal
because patient centered ness requires that you appropriately
prescribe and sometimes that’s less and sometimes that’s not
the other problem is writing the script. Is this one moment in the
prescribing relationship right. And there’s a whole bunch of
other moments. And so some of that is
counseling the patient beforehand and making sure
they’re ready for pain and so that they rely on the medication
lesson that you have an exit strategy and then a whole bunch
of happens afterwards is managing the patient in the
prescription longer term to make sure that you can actually D
prescribe as appropriate. So here are two points on the on
the nice Pickering pathway of the four finding quadrants you
have you know prescribing and non prescribing options that’s
upfront kind of supply reduction. If we’re over supplying and then
there’s management of long term prescriptions and that’s part of
management. So best work in particular is
really important for this this population of legacy patients
some of whom are orphan patients now without a prescribing doctor
because we need to prescribe people on hundreds of morphine
milligram equivalents of medication that’s an important
part of not contributing the epidemic. Making sure that people are on
dangerously high doses can safely and effectively when
they’re ready and a patient centered way reduce that
prescription. But there’s also this category
in the middle and that is routinely prescribing. And that’s what failed with me. And think about how often this
happens every orthopedic surgery every CIS area in session
cesarean section every routine surgery of every kind that
requires at least a few days of opioid allergies. Right. Oftentimes we’re overprescribing
anyway and sending them home with two weeks or three weeks
and that’s bad. But whether you’re
overprescribing or prescribing appropriately you have to make
sure the patient has a way to get off the pills that you
prescribe. So that’s my time. Thanks very much. Happy to answer questions. All right I want to thank all of
our excellent panelists and discussions for for re really
teeing up the what will happen next which is a discussion with
with all of you. So we there are microphones in
the aisles on both sides of the room I’d like to invite you two
to come up with comments and questions. We have just just almost a half
an hour before before the session ends and thank you very
much for this really fascinating talk. Really a lot of practical points
about patients practitioners and patients and providers. So my name is Maleeha Ali. I’m with the American Institutes
for Research and I’m curious to know especially for doctors
during now and gasoline. Could you describe some of the
barriers that you’ve seen working with providers on both
providing treatment for opioid use disorder and also with
providing treatment or providing appropriate pain management. You did mentioned after rescuing
that the majority of physicians who have buprenorphine waivers
are not prescribing that and I think this also if you can tie
that into how this could be linked to stigma and within the
delivery system. Thank you yeah. The reason we think that most of
the physicians and I’m talking about many thousands of
physicians across the country who’ve been wavered but won’t
prescribe it seems to be the one the concern that they really
don’t know how to do it and if they get into trouble they don’t
know where to turn. It’s a partial agonist. So it has some challenging
issues of initiation and dose management. But the bigger problem I suspect
is fear that they will become a magnet for difficult to treat
patients who will alter the climate of their waiting room
and scare off their other patients. Now Vermont and other states you
just heard Pennsylvania is doing this have developed a hub and
spoke model where the specialty hubs initiate the patients
stabilize the patient provide the psychosocial grounding in
the context of the medication and then they transfer the
patients direct care to primary care in the community where a
provider gets where wavered and has support from the specialists
day to day week to week month to month and feels that they won’t
be left to drift and they’re getting a patient who’s already
stable. So that’s a very fruitful model
for overcoming this problem and I’m I’m thrilled to hear that
Pennsylvania’s making use of that and other states as well. But it’s it’s a big problem in
getting access. Thank you for the question. Can you hear me OK. So I have two different aspects
to my response. The first is that the first main
barrier is education. So veterinarians receive 28
hours of pain education in training physicians receive
between four and 11 hours across four years of medical school. So the physicians that enter our
communities are ill prepared to manage the complexities of
people they’re trained to deal with symptoms to write
prescriptions. So that’s number one. And we could extend this across
professions it’s not just physician training it’s physical
therapists psychologists psychologists receive zero pain
education systematically throughout training. And so that’s a lost opportunity
to address the psychosocial dimensions because there’s huge
coma comorbidity between pain and mental health conditions. So that’s number one is
education is needed. Travis also referred to the fact
that once a prescription is started you know physicians and
prescribers lack the education for how to prescribe. But the second piece to my
response is that there are barriers in terms of resources
so we can train physicians we can train health care clinicians
and they could say great I want to prescribe self-management or
psychological approaches or an interdisciplinary approach. And then what we find is that
there’s barriers to accessing these evidence based treatments. So we can develop all the best
treatments in the world. But if our patients can’t access
them it means Squanto. So we need better allocation of
resources towards education and also models of delivery of care
models that are truly accessible. And I believe that this will
eventually come down to some of these more Internet based
approaches as a frontline and that was discussed in this
session. That’s where some of my work is
focusing as well because we’ve got to transcend the current
issues around proximity and also education. Thank you very much. So Kevin Haynes I’m a pharmacist
and an epidemiologist from the P.I. of health plan research
network. I wanted to talk about the data
gaps in being able to close these gaps in evidence so very
much I’m also a resident of the Commonwealth of Pennsylvania. So very excited to hear all the
work that’s being done there. When you have state prescription
drug monitoring programs that that have real rich exposure
data but then you have administrative claims Medicaid
commercial claims Medicare claims that have the rich
outcome data that cross and transcend health care system. So in other words if I get a
prescription because of a surgery at Penn hub at Hofstra
University Pennsylvania. But I have an opioid overdose
thing at Temple. There’s so much fragmentation in
the health care system and health plans are trying to
provide care management health systems are trying to provide
care management. So we need to link the data and
I’m finding it incredibly challenging for health plans to
link into this high quality exposure data because we’re
missing the cash paid prescriptions and we’re doing a
disservice we can’t really provide high quality care or
high quality evidence generation without data linkage. So I wonder what the panel and
especially Dr. Kelley with regards to from a state
perspective is as well on the need for data linkage to close
gaps in evidence to ultimately close gaps in care. Thank you. That’s an excellent question. Unfortunately in Pennsylvania we
have an excellent PD MP that’s been operationalized over the
last two years. And I think that overall
prescribing of opiates is down. I’m going to say at least 10 or
12 percent and there’s been a significant reduction in
providers are using it. And there’s been a significant
reduction in individuals that are shopping from provider to
provider. But with that being said
Unfortunately the law does not allow us even as a Medicaid
agency I can go in and look at it and I can look at on a case
by case basis I can’t push that data or that information to our
health plans. We also we have a lot of claims
data and we actually have worked with the University of
Pittsburgh to develop an overdose predictive model for
who is who will have the next overdose. And we ran that across our
claims data and I was told I could not push that out to our
managed care plans because of our confidential state
confidentiality regulations. So we did give that model to our
health plans and said Go do it yourself. So there are some barriers out
there unfortunately. We’re trying to break some of
those barriers down there. There was I believe a bill that
was circulating in our assembly to actually have our managed
care plans get access to the PD MP information. So there are some challenges on
the other hand putting on the head of a consumer and a patient
confidentiality laws are there for a reason. There is a lot of stigma. There’s a lot of discrimination. We’ve seen it especially in the
past with HIV patients. We’re continuing to still see
that with a use disorder. So I understand it is a
balancing act but I think there it would be nice if we could
break down some of these walls where we could judiciously share
information that’s going to help patients and not harm them. Yeah and I would add that if we
could get national data harmonization really working
with PD MP and privacy law worked through to allow the data
sharing that you’re calling for we’d still have the problem of
physicians taking the active role of checking the PDP prior
to prescribing and prior to refilling and we could get a lot
of help if the Joint Commission would undo the damage it had
done when it invoked the requirement that you check pain
as the fifth vital sign which was destructive because suddenly
every doctor working in a health care system was obligated to ask
essentially is your pain zero because if your pain is not zero
I should be prescribing some opioids for you. And that’s inevitably what
happened and we’re gonna have we’re gonna be paying for that
for another decade. The Joint Commission could
require the percentage of times that a prescription of an opioid
in the H.R. record is associated with a check of the PD MP. It’s a simple almost trivial
electronic programming task. And so we could actually be
reporting and obviously every physician under those systems
would then do it and it wouldn’t have to be an active act. It could be a passive reminder
to the physician. So it needs to be incentivized
that physicians use the care and caution that’s required in this
kind of an epidemic great. Thank you. Next question. Thank you. My name is David Iggy. I’m the founder of M.C. N. It’s a national care
coordination in telemedicine network. And the reason I came today I
want to hear from distinguished panel as well as maybe the
audience how to implement that ongoing communication between
providers and patients guarding the opiate use after the
treatment has been done on an ongoing basis. And if there is I mean practical
ways how to do that. What do you think could be done. Those methods. And second if there is currently
any way to reimburse the providers for that extra time
which is ongoing as I said thank you for that question. We do not have sort of an after
care component in our PCORI funded study in the Empower
study where we’re following people for one year and they get
our behavioral treatments and they’re slowly reducing their
opioids. But one of the one of the
pathways under consideration and we deliberated about this was to
integrate in peer support groups from the American Chronic Pain
Association. These are free peer support
groups that are provided around the United States so you can go
to the a CPA dot org Web site and learn about them. They’re not. This is not specific to opioid
use disorder. This is specific to
self-management of chronic pain. And there was just through the
vagaries and complexities of research it was not a good fit
for our current study but we do offer that in not at the
Stanford Pain Management Center and throughout the United
States. And what’s nice about it is it’s
free. So the only burden is for the
the host to provide space. The ACA helps identify peers in
the community who become leaders and support others through
better management of pain. But as far as the opioid use
disorder I would defer to the other panelists and yet any
further comments come as a pair for telemedicine. I would say that Pennsylvania
Medicaid we have policies in place where we would pay for
telemedicine done on an outpatient basis and we’ve told
our providers that that is something we’re willing to
reimburse for. It’s the typical billing
requirements through an enum code. It is available. We we feel that the DEA earlier
this year gave guidance that brought down some barriers for
doing m80 via telemedicine. So it is something that within
the Commonwealth we have already put the policy infrastructure in
place to make that available. One of the issues though is that
from a counselling standpoint because we are very restrictive
in Pennsylvania you can’t get drug and alcohol related
counseling unless you physically go to a drug and alcohol
counseling treatment center. So it’s a huge barrier. And so even from a telemedicine
standpoint there are barriers to having that counseling portion
of medication assisted treatment done via telemedicine. Now there’s some caveats we
always feel that that face to face connection is the most
important and we don’t really want to see telemedicine replace
that face to face. But there’s some rural areas
where access is more of an issue and certainly we would advocate
that folks could use telemedicine but we really don’t
want it to totally replace that face to face connection that we
think is vital with providers. All right. Thank you. Next question Hi I’m hop
restaurant my counsel a medical specialty societies I’m also on
the steering committee of the newly launched National Academy
of medicine’s collaborative to counter the opioid epidemic. And the reason I want to mention
is you’ve brought up so much rich research findings that are
coming out of this the collaborative is really all
about a public private partnership to address and
implement some of these findings. I think there’s a real
opportunity for us to think about where can a public private
partnership at least initially our workers really focus on
education and training prescribing guidelines and
standards as well as prevention treatment and recovery with a
cross cutting emphasis on both research and stigma. To your earlier point David. So we just welcome your thoughts
about where you see that the critical linkage between this
incredibly important research and how we actually can think
about implementation rapidly to address the epidemic using a
really unique public private partnership with health systems
public health systems all the table together. You all say something about
that. One of the remarkable things
about Pickering funding that is so different from NIH funding is
that in our study we were funded for a dissemination phase after
the main trial. So just to do an 800 patient
randomized comparative effectiveness studies is
remarkable enough but then to have another year of funding to
disseminate the results and to have a stakeholder steering
committee from the inception of the protocol development to
bring together professional societies patient advocacy
groups provider trade associations funders in the
oversight of a study from start to finish that’s something that
you only get in a PCORI type of project. So I think what you said is
really important and I’m really grateful because it stretches
the researchers to realize that they’re not done when they
publish the paper. Maybe just to add to that I
think in addition to the implementation and I know Craig
does a great job with that piece of it there is an effort here to
try to scale it as well. So how do you move beyond what
you’ve learned and think about how you scale it at a national
level which is really where I think the part of the
collaborative I would like to emphasize. I’m sure David has something to
say at least at the state level. We would certainly be willing to
look at a lot of the research that’s been done here to
disseminate and especially when it comes to payment models and
especially working with or UHC as we have a great network of NQ
agencies and in Pennsylvania we’ve already had some
discussions at the statewide level to really more widely
implement m80 within our F Q Eight C’s and to do it with a
high fidelity model. We’re already putting payment
mechanisms in place for some of the care management it gets a
little tricky because of how F Q H agencies are reimbursed. But we certainly would want to
disseminate those findings. I think the findings around how
to treat chronic pain in a multidisciplinary mode we’re
already moving Geisinger Health systems already put together and
two sites in rural areas and the Allegheny Health Network system
in Pittsburgh have put together these multidisciplinary and
outpatient pain management clinics that hopefully have been
very person focused too. We really want to see the
dissemination of those models but we’ve tried to expand we
allow our managed care plans to pay for acupuncture we pay for
chiropractic we’ve reduced prior authorization requirements on
non opioids. So we’ve tried a whole host of
things but we’re the state at least is very much so interested
in being able to disseminate these concepts I think
nationally our Medicaid medical directors are here this week for
the next two days rather to talk about the opioid crisis and
other topics. And one of the things that we’re
going to have discussions around is how do we had all my
counterparts in their 46 states that will be meeting that will
be represented. How do we disseminate these
things not just in the state of Pennsylvania but in these other
state Medicaid programs. So we’re very much so interested
in taking what this research shows us and disseminating it
especially in the state Medicaid programs. So I’d just like to add to that
that while there’s a huge emphasis on treating pain
better. One of the key foci is how do we
help these 18 million Americans who are currently taking
prescribed opioids and reduce their use. So we really need solutions
urgently because there have been there has been advice from the
CDC and other agencies to reduce opioid prescribing and
physicians and prescribers in the communities are not trained
to implement this. And it puts our patients at risk
yet again when we’re not tapering the right way. So I believe that part of this
private partnership what we need to be focusing on is developing
online implementation strategies that use best practices their
physician portals prescriber portals also has a patient
facing web site and resources so that we can rapidly scale and
address the needs of Americans today not a decade from now or a
decade and a half when medical education catches up with what’s
happening right now I also would like to add. Thank you David for mentioning
the primary emphasis on dissemination. We do as one of the criteria for
review we look at what what is the disseminated ability and if
that’s a word of of this intervention should it show
effectiveness. And also how scalable is it. And and if the answers to those
are well probably not going to happen then that really kind of
stops the whole process. All right. Thank you. Next question. Hi my name is Katina Lang
Lindsay and I am a kidney transplant patient a part of the
ambassador program here and also I am on a study called putting
patient It’s a PCORI study putting patient at the center of
Kidney Care but also I am a professor at Alabama State
University and social work department and my I don’t think
I have a question but I think I have more of a consideration and
my consideration is Have you considered social workers as
being persons to help with the psychosocial components of what
you’re doing. And the reason why is because
clinical social workers have clinical social workers who are
able to play more than one role in the whole capacity. We both can help with the
psychosocial. Then we also can help with the
resources that serves that serves its own entity but not
only that we are able to beall at the clinical level and be
able to help. So we are a resource that can be
used and I think sometimes it’s unfortunate that we do not get
the opportunity to be used. And I think that’s a bit a big
part too as it relates to being a part of the multidisciplinary
team is that if you will consider that aspect and I think
it would be helpful. Also my last comment is in
regards to tell a medicine a colleague and I are working
towards now telemedicine use mental health in rural
communities and that’s one of the things that I believe that
we could also be used in because we also know that we could also
be used in that area in terms of billing. I think in with the federal role
community health centers we could also be an asset to them
in getting those mental health services that otherwise cannot
be get him for those persons that are in rural areas. That’s. Thank you. Thank you. And we have time for one. One final question or comment. Thank you. Jazz saying University of
Alabama at Birmingham clinician researcher. Very nice presentations. My questions are frequently and
I think as one of the discussions brought up after
elective surgery or surgery in general patients get two or
three weeks of pretty good doses of opioid medications and then
they’re left right there either to seek that back from their
primary care physicians and or figure out how to get them off. Now we know that the training if
concessions is limited with regards to opioid prescription. So what are your thoughts about
what sort of models because here’s a challenge about
inadequate knowledge transition of care major surgery you know a
patient grappling with all these things and so is the system and
there is transition of care occurring. A good example is you know joint
replacement surgery one million knee’s done in the US in the
elderly population primarily two thirds of them and they all get
opioids and some of them have never seen opioids and others
have had that experience so what do you think. What sort of model might work
with this transition of care opioid prescription challenge so
I have a couple of studies that are targeting this exact issue
right now they’re not funded by PCORI but what they involve is
training the unit staff the physicians and the nurses on how
to talk to people about pain and how to address pain non
pharmacologically. That’s not to the exclusion of
opioid medication. It’s equipping patients and
providers with the information for how to treat pain
multi-modal Lee and how to empower patients to go home and
reduce reliance on the opioids that they may have used in the
hospital. So that’s one piece of it the
other piece of it is we’ve developed behavioral digital
behavioral medicine treatments so that when a patient goes to
surgery we can characterize their needs and we can deploy an
e-mail to them that includes a behavioral pain medicine
intervention which they can receive before surgery or after
surgery. So these are some scalable
options that we’re focusing on. Dr. Reeder did you want to make
one final comment make our final comment. Yeah. One quick thing. So I’ve worked with a couple of
hospitals on this sort of question and so one private
hospitals and orthopedic surgery hospital and one of the things
we learned really quickly is the one. It all has to be contextual so
what works. Johns Hopkins which is hugely
different from the specialized orthopedic surgery hospital
they’re not going to work in the same way. And the other thing is it’s not
clear that there’ll be any one right answer. But it has to be addressed
structurally. Right. And so in this orthopedic
surgery hospital one of the things we talked about was
training in P’s and PA’s who do a lot of the discharge
prescribing to do this sort of exit strategy mapping follow up
care that having scripted conversations that can identify
behavioral health assessment needs that sort of thing. But it’s not clear that’s the
only solution is what would work for them given that orthopedic
surgeons are not going to be spending their time doing this
right. So that’s right. Thank you. Thank you so much to our
speakers once again to a round of applause for our speakers and
for all of you in the audience for participating today.

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