Articles, Blog

U.S. Surgeon General Leads Panel Discussion on Combating the Opioid Epidemic

December 24, 2019

Good afternoon, everyone. I’m Jeff Flier, Dean of
Harvard Medical School. And it’s really a great pleasure
to welcome you all today to the grand
rounds, as we gather to address the
current opioid crisis and together work
toward solutions. It’s certainly one of the
most important and troubling public health challenges facing
our communities and our nation today. Right now, four
people die each day of opioid overdoses in
Massachusetts alone. And since 2004, more than
6,000 have died in this state. Governor Baker’s administration
has recognized and quickly risen to the challenge,
establishing the state’s Opioid Addiction Working Group,
which has taken a leading role in addressing this crisis. One of our HMS assistant
professors in psychiatry, Todd Briswald at
Cambridge Health Alliance, has been working with
that state group, which includes professors and
faculty from four Massachusetts medical schools. I’d also like to
recognize at this time the work of the Massachusetts
state legislature, especially the leadership of
State Senator John Keenan, who is with us today,
and any other elected officials who might be here. Thank you. We’re all working to further
develop our curriculum competencies so
that we can improve how we teach future physicians
better pain medicine prescription practices
and give them a more accurate understanding
of the signs of addiction. And we’re also working to
de-stigmatize substance abuse disorders. Along with that,
planning is ongoing as to how we’ll integrate
the new curriculum across all of our teaching
hospitals and throughout the multiple clinical
areas outside psychiatry. But, as most of you
are probably aware, solving this complex
health problem is very difficult, because
prevention and treatment of opioid use disorder
is intertwined with the many challenges
involved in humanely supporting people who are struggling
with chronic pain, addiction, and other behavioral
health problems. In addition, many face
structural barriers to good health, including
poverty, homelessness, and other social challenges. But if there is one
thing that we’ve learned through
basic science, it’s that solving the hardest,
most complex problems requires collaboration
and partnership across diverse labs, academic
disciplines, and institutions. At HMS, we are
working to marshal the considerable
resources of our school, our affiliated hospitals, and
our clinics, several of which are leaders in the
treatment of addictions and behavioral health, along
with our external education programs and our Center
for Primary Care, all together to effectively
confront and rapidly reverse this devastating epidemic. So all of this brings us back
to the work of our meeting today and the introduction
of our guest panelists. First, I’m delighted to
welcome Dr. Monica Burrell, Commissioner of
the Massachusetts Department of Public Health. Dr. Burrell’s department is
responsible for spearheading our state’s response
to the opioid crisis. Welcome back to Harvard,
Commissioner Burrell. [APPLAUSE] Next on our panel is Dr. Sarah
Wakeman, an Assistant Professor of Medicine here at HMS,
and Medical Director of the Mass General Hospital
Substance Use Disorders Program. MGH developed this
program as a new approach to opioid epidemic,
and it has made it one of the highest
clinical priorities of a hospital-wide
strategic plan. Welcome, Dr. Wakeman. [APPLAUSE] And our third guest
panelist is Michael Duggan, who can speak very personally
about the opioid crisis. An Arlington native,
Michael is the founder of Wicked Sober, an
organization that helps individuals and
families struggling with addiction by connecting
them with treatment resources. Welcome, Michael. [APPLAUSE] And finally, our very
special guest today– let us all welcome US Surgeon
General Vice Admiral Vivek Murthy. [APPLAUSE] Thank you very much. Thank you so much for
that warm welcome. It is so nice to
see so many friends in the audience–
Bill [INAUDIBLE], you in particular–
and so many others. Dean Flier, thank you
for that kind welcome and for welcoming
me back to Harvard. It is really nice to be here. I have actually spent a
lot of time in this room in particular. And I remember so vividly,
as if it was yesterday, just how many
amazing experiences I’ve had in this
system, training at Brigham Women’s
Hospital as a resident, working there as an attending,
having the incredible privilege of teaching students during
my time in residency. And all of that has just
been an incredible privilege. And I’m reminded of that
when I come back here today. So I just want to
thank you for that. I also want to tell
you that– you probably know a lot about what
the Surgeon General does. But I find often when I
travel that people have heard about the Surgeon General. They know the Surgeon
General exists, but they have no idea
what I actually do. And I often find
that people have these strange misconceptions. They recognize me from
a box of cigarettes or from a bottle of alcohol. [LAUGHTER] And they think that’s
my main job, is stamping boxes and the bottles. [LAUGHTER] And it happens at
least once a week or so when we travel
that I get mistaken for an American Airlines
pilot because of the uniform that I wear. [LAUGHTER] But I’m assuming all
of you know better. I do not work for an airline. But instead, my job as
Surgeon General is twofold. It’s to ensure that
people across our country have the best possible
information that’s scientifically
grounded that they can use to improve their health. But it’s also to oversee the
United States Public Health Service Commission
Corps, which is a group of 6,700 officers
all around the country, and in fact, around the
world in 800 locations, who have dedicated their
lives to improving public health in America. These are doctors and dentists,
nurses and physical therapists, pharmacists, environmental
health experts, veterinarians, and even public
health engineers. And I bet you didn’t know
that there were public health engineers, but
there actually are. And they respond during
times of emergency, like in hurricanes or
tornadoes, that compromise the health of our country. They also help ensure
that on a day-to-day basis that our federal agencies
are doing everything they can to improve the
public health of the nation. And that is actually the
reason why I wear this uniform, is this is the uniform of
the US Public Health Service Commission Corps. I’m glad that we’re
all here today to talk about opioids, because
a few days ago I was in Phoenix. And in Phoenix, I met
an incredible young man who works at a center called
Community Bridges, which is a substance use and
addiction treatment center. And he told me this story of
how, when he was a young man, he felt like he
didn’t quite fit in, always felt something
was strange about him. And the first time he really
felt normal or comfortable was when he took
prescription opioids. And he remembers
that moment vividly, because it was the moment
where he got hooked. And as he tells it, he
began taking more and more of those prescription
painkillers in the months and
years that followed. He even told me at one point
that a couple years after he finished high school, he
was actually diagnosed with testicular cancer. And he went through a
pretty major surgery. He was treated, and he was told
that he would hopefully be OK. But three years
later, he was found to have enlarged lymph
nodes in his abdomen, and was told that there was a
recurrence of the testicular cancer. Now, for nearly anyone in this
room, if we were in a position where we were told we
had a recurrent cancer, our reaction would probably
be one of sadness and dismay. But that wasn’t
the case with him. He was actually overjoyed. And he was overjoyed
because he figured he’d need to have
a major surgery and would likely get
more prescriptions for opioid medications. He told me that story
to illustrate just how powerfully addiction
can take hold of your brain and impact the decisions
that you make and corrupt your judgment. And that’s what he experienced. That’s what so many people
living with addiction experience each and every day. So this is really
quite profound. And when we look
at the numbers, we find that there are
nearly two million people in our country who are addicted
to prescription opioids. And we see that there are
also millions more who are impacted by family members,
friends, teachers, and people in communities, including
doctors and nurses who are caring for these folks. A question is how
did we get here? Well, about 20 years ago, as
many of you may well remember, clinicians were urged to
treat pain more aggressively. But they were urged
to do so often without being given the
training and the tools that they needed to
understand how to treat pain safely and effectively. This also coincided with heavy
marketing of opioid medications to doctors. And many of us were even
taught that opioids were not addictive, as long as
they were given to someone who had legitimate pain. I was having dinner with a
friend who’s a cardiologist down in Florida the other day. And I mentioned this
to him over dinner. He put down his fork,
and he looked up at me, and he said, wait, you
mean that’s not true? And he was trained
at some of the best programs in our country. So there’s a lot that
contributed to this problem. But what it’s led to is
unfortunately a quadrupling in overdose deaths since 1999. The quantity of
opioids prescribed has also quadrupled since
1999, tracking very closely with the rise of the epidemic. So what does this mean? Well, it means something
in very real human terms, because besides the
numbers that tell the epidemiology of the illness
and how much it’s costing us in terms of dollars, there’s
a very real human cost, a cost that I see very
often when I travel around the country and talk
to families, a cost that many of you see in your
day to day clinical practice, recognizing that so
many of our patients, whether they come in with
a primary complaint that’s linked to addiction or
not, often have addiction in the background, something
that we have to be aware of and we have to manage
if we want to improve their overall health. So what do we have to
do to get past this? Well, I think there
are a few key things. And the good news is
that a lot of this is actually being done
in Massachusetts, which is exciting and encouraging,
and a reason why I think this state is a
bright spot in the country. But we have to ensure that we
are sharpening our prescribing practices as clinicians so
that we can prescribe opioids when necessary but avoid
them when they’re not. We also need to ensure that
we are expanding access to treatment, that we
are getting naloxone in the hands of people who are
at risk for overdose, as well as first responders and, in
some cases, family members. We have to educate the public. Many people in the
public don’t also recognize that
opioids are addictive. As one patient’s family
told me, a patient who sadly had a child who overdosed and
died from opioids– her mother said to me, I got a
prescription from the doctor, so I assumed it was safe. Why would our
doctor ever give us something that could
kill our daughter? That’s what she said. And unfortunately, there
are so many parents that have gone through a
very similar experience. So we all know, as clinicians,
that every medicine has benefits and potential risks. But when it comes
to opioids, it’s clear that we have to do more
to help the public understand what some of those risks are. And finally, what
we also need to do, which is perhaps more
difficult than anything else, is we have to change how our
country thinks about addiction. We can’t pass a law
that will do that. We can’t build a single program
that will change attitudes around the country. But right now, there are
too many people in America who think of addiction
as a character flaw, as a moral failing. And as a result,
it makes it harder for people who are living with
addiction to come forth and ask for help. It makes it harder for
people to accept treatment centers in their neighborhoods. There are so many
people who would have no problem with a cancer
treatment center being set up in their neighborhood or a
heart disease treatment center. But when you talk about
having a methadone clinic in their neighborhood, that’s
a whole different issue. And many of them are
concerned about that. And why is that? It’s in part because of how
we think about addiction. So that’s something
that we have to change. And our office made a decision
very early on in my term that I would make this
a priority during 2016 and the years that followed. The reason is partly because
of my own clinical experience, seeing so many patients
struggling with addiction. Part of it also had to
do with nurses at Brigham and Women’s Hospital,
who, on my last day– actually at the Brigham,
when I was leaving– pulled me aside and said,
Vivek, if you could do just one thing during your time at
Surgeon General, please do something about the
drug crisis in America, because it’s tearing
our communities apart. But I also decided to make
this a priority because of the families that I met all
around our country, families who said to me time
and time again, please do something to help us. Our communities are struggling. So that’s why I have
made this a priority. That’s also why
President Obama has made this a priority, because
he too has heard from families. He too has seen the pain
and the cost of addiction all across America. So in addition to visiting
communities like Boston, where we can talk about the
challenges that we are facing, but also the solutions
that we’re implementing, I will be, next month,
issuing a letter to the 1.2 million prescribers of opioid
medications in all 50 states, a letter that will urge our
colleagues to join a movement we are building to turn the
tide on the opioid epidemic. We will also urge
practitioners to follow a key set of best practices
which will help them treat pain safely and effectively. And since, as clinicians,
we all love pocket cards, we’ll also be including a
pocket card in that letter so that you can keep
that in your white coat or, increasingly, in your
black fleece as many of us seem to wear. And that’s something
that you can refer to that will
help guide you when you’re making decisions
about opioid medications. And later this year, I will
be issuing the first ever Surgeon General’s
report on substance use addiction and health. Surgeon General reports
have been an important part of how we have addressed public
health crises in this country. In 1964, my predecessor,
Luther Terry– who, by the way, lived in Brookline also. But Luther Terry issued
the country’s first report on tobacco, which began
50 years of activity in reducing smoking rates that
helped us go from a smoking prevalence of 42% in
1964 to under 17% today– still too high, but
progress has been made. And the goal of
our report will be to bring together the
best available science on prevention,
treatment, and recovery so that clinicians
know what to do, so that policymakers
know what to support, and so that families
know how to approach their children or
their loved ones when they’re dealing
with addiction. That’s a purpose of our report. It’s also to help us change
how our country thinks about addiction. In closing, I just want to
share one last thought, which is a question about
whose responsibility this is to solve. We have so many crises
in America right now. And often, when we
think about them, we can ask ourselves, well,
one, whose fault was it, and two, who should
clean up the mess? But what I want to tell
you with this problem, with the opioid crisis,
is that this is not any one group’s responsibility. This is all of our
collective responsibility. This is a problem that can’t
be solved unless policymakers and clinicians work together
with families and faith leaders to change not only how
we think about addiction, but how we prevent and treat it. And we have an especially
important role, though, as clinicians to play here. And you might think,
well, that’s of course, because we can prescribe. And if we can change
prescription practices, then we can impact
this epidemic. And you would be
absolutely right. But I think there’s
something even bigger, which makes it important that
we in particular step up. And that’s that
over the centuries, society has accorded us a
special place, a special degree of respect that comes from
an appreciation for why we enter this profession
in the first place. Many of us came to
the healing arts because we wanted to
relieve suffering, because we wanted to
improve people’s lives. And with that has come
a moral responsibility to not only care for
individual patients, but to step up and
help address some of our country’s most
intractable public health problems when they arise. I learned early on when I was
young, as an elementary school kid sitting in my
parent’s office, where they saw patients
day in and day out, that they was something
more than the science that was contributing to that special
look of respect and honor that my parents’ patients
accorded to them. My parents– their
patients looked at them for hope and for help
during times of hardship. Their community looked
at them for hope and help during times of crisis. And the opioids crisis is
one of those moments where the country is looking to
our profession for hope and for help. And my desire, my
hope is that we will step up, that we will
fulfill that responsibility. So part of the reason
we’re here today, and why I’m so thrilled that we
have a wonderful panel with us, is that we want to talk
through some of what’s actually happening with this crisis and
how we’re addressing it here in Massachusetts. We want to talk a little bit
about how individual clinicians can change their practice
and can play a bigger role, in fact, in helping to not only
prevent addiction, but treat it as well, particularly
with buprenorphine. And we want to hear a bit
about the experiences of people who have lived through
addiction and who have come out on the other
side and helped show us that recovery is
not only possible, but that the story of
getting to recovery can be a source of empowerment
for many, many others. So with that, I want to turn our
discussion over to the panel. I’m going to begin by
addressing a couple questions. And you can all
still hear me, right? Yes. Mic is officially working. I start by addressing
a couple questions. And then we’re going to
open it up to the audience so that all [INAUDIBLE] have
some time to [INAUDIBLE]. Wow. [INAUDIBLE] All right. Let’s hope it stays. So I want to start
our first question with Dr. Burrell, our
Commissioner of Health here in Massachusetts. First of all, Dr.
Burrell, thank you so much for being with us today. And you have played
multiple roles when it comes to medicine
and public health during your career. You’ve been a clinician. You’ve treated patients with
substance use disorders. And now you’re also
looking after the health of the entire state. So I’d like you to share a
little bit with us about what approach Massachusetts is taking
to address the opioid epidemic, and in particular, how
is the state interfacing with clinicians? Sure. Well, first, everybody,
thank you all for being here. It’s nice to see so
many familiar faces. And I want to, on behalf of the
Baker Administration, welcome the Surgeon General here. It’s quite an honor for us to
have our National Public Health leader coming to Massachusetts
to learn about what we’re doing to battle this opiate crisis. As many of you know, this is
the number one public health issue of our administration,
and we are working very hard to bring down the death levels. The numbers are astounding. There were over 1,500
predicted deaths last year from opiate overdose. And that’s over
double just 2012. When we think about those
numbers and the individuals behind them, we
have come together, Governor Baker put us together
as an opiate working group cross-sectorally, and we came
up with 65 recommendations and a 19-step action
plan that looked across the area of prevention,
intervention, treatment, and recovery–
many of the points that Dr. Murthy raised to
make sure that we address this issue across a sector. In prevention, we’re talking
about prevention, crime rate prevention, so that individuals,
parents, students, coaches, community members understand
the risks of opiate misuse. And then we’re talking
about prescribers. As many of you
know, Massachusetts is, again, first in the nation
to have all four medical school deans– thank you, Dr.
Flier for your leadership on this– all four medical
school and dental school deans have adopted a core competency,
10-core competencies, that we will teach every medical
and dental student before they graduate so that
we’re all starting with the same basic individuals
enter their clinical practice. In interventions, we are looking
at getting naloxone or Narcan throughout our communities. We’re increasing the
number of treatment beds. And we’re working
towards improving the options for
recovery, including recovery homes and
sober home living, as many individuals
find themselves tackling unemployment and homelessness
as well as they struggle to get better. I will say, the most
important thing to me is our State Without
Stigma campaign. And when Dr. Murthy
and I earlier today were speaking with
some patients, when we asked them, what
would it take for you, what advice do you
have for individuals– and he spoke about
his own struggles with getting the courage to
tell people in his community or his medical provider
or his own doctor that he had issues with
substance use disorder because he was embarrassed And for us, we have to get
over this issue of the stigma. This is affecting all of us. We have to look at
substance use disorder for the medical
disease that it is. And until we get
there– and that’s both from us and our internal
biases as prescribers as well as community members–
until we get there, we won’t be able to
make sure that all of these services that we have
are accessible to everyone. It’s a big barrier,
the stigma issue. Well, thank you. Thank you so much. And I certainly appreciate
your efforts and the governor’s efforts in this state. So please, convey our gratitude
to him for what he is doing. I want to turn to Dr.
Wakeman for a moment to give us a bit of a
clinical perspective here. You also have
trained in medicine. You’ve seen the many
facets of addiction. You’ve now come to a place
where you’re treating people who are living with addiction. And I want you to help
us address something very practical
here, because I find that when I speak to
clinicians, and when I think about my own time
practicing here at the Brigham, the prospect of
treating patients with substance use
disorders seems like a monumental challenge. It seems like the amount
of work and training that would be required to
be able to do something like prescribe buprenorphine
would be incredible. And this is even when you’re
sitting at academic center, where you have some
additional sources of support. So what I’d love
for you to demystify for us is what is
treating substance use disorders actually like? If we want substance
use disorder treatment to be part and parcel
of training for everyone in medicine, do you think it’s
practical for someone who’s practicing primary care medicine
right now to take on substance use disorder treatment? So I would love for you to
comment a little bit on this. Thank you. And thank you so much for
being here and for having me. It’s an incredible honor
to be on this panel. So I think that’s
a great question. I actually was a
primary care resident. I trained in the
primary care program at Mass General Hospital. And I’m a primary
care physician and I’m board certified in
addiction medicine. So I do both. And I would say that
treating addiction is both the single
most rewarding thing I do in medicine and
one of the easier things that we do in medicine. As internists and
as specialists, we take care of very complex
chronic medical disease that has components of behavioral
parts of people’s lives, genetic risk, and sort
of fundamental biology. And addiction is exactly that. So I actually think
diabetes is sort of the perfect metaphor for
both how we deliver care and what the disease is. So addiction is as genetically
inherited as diabetes. It’s about 50%,
based on your genes. And like diabetes, there
are some components of lifestyle or exposure. And then there’s
a lot of biology. So patients who have
addiction, their brain is fundamentally changed. And the story that you described
is a perfect description of what happens–
that, by definition, people who are in the throes of
addiction behave irrationally. And I think that’s
one thing that’s so hard for family members and
for the public to understand, this idea of sort of why
can’t they just stop? And literally, the
part of our brain that helps us make decisions
about choice and to weigh risk and benefit and think
about consequences gets damaged in addiction. And the good news is
that recovery happens. Actually, most people with
addiction will get better. It’s a totally
treatable illness. But it takes time, like
other chronic diseases. And if patients die
before they get there, obviously, we’ve
lost the battle. And so I think the approach
is very much what we do in primary care every day. It’s meeting the
patient where they are. It’s patient centered. It’s a shared decision
making process around what type of treatment
works for that patient. And it’s a combination
of medication and behavioral interventions
or lifestyle interventions. And so I think it
maps out perfectly into what we’re doing. But the big thing is stigma. And that’s what Commissioner
Burrell mentioned. And with medication
treatments in particular, I was actually on a
panel earlier this week with a gentleman
who’s in long term remission on buprenorphine. He’s been in remission
for eight years. And he said that it was harder
for him to tell his family that he was on buprenorphine
than it was for him to come out as a gay man, that he
felt such intense stigma around the use of medications. And I have many patients who are
doing fabulously in recovery. They’re working wonderful jobs. And they don’t tell
anyone that they’re on this lifesaving
medication because they perceive this message that
somehow that treatment is not valid. And so I think fighting stigma,
not just with the disease, but actually with the
types of treatment that we offer people is crucial. Well, that’s very,
very powerful. And I would also just
want to flag for folks when you actually look
at how much time it takes to get trained at administering
buprenorphine for the waiver, it’s actually about eight hours. That’s the length
of the training. So it’s achievable. It’s actually easy to do. And it’s incredibly gratifying. This is the piece, I think, that
many clinicians who have not actually engaged in treatment
don’t necessarily understand, is that we are living in a
time where physicians are burning out at very high rates. And part of the reason
that we’re burning out is we often don’t feel we
have the tools and the time to treat the challenges
that our patients have. And that lack of
self-efficacy, when it happens year after year
after year, can burn people out. And if training and treatment
actually gives you the ability to have impact– and
I believe that impact is one of the most powerful
antidotes to burnout. When you feel like
you can actually have a positive impact
on a patient’s life, that gives you energy. It gets you excited. It renews your sense
of mission and purpose. And so I would certainly
love to see more clinicians, especially primary care
clinicians getting trained in buprenorphine treatment. That’s part of what we’re
trying to encourage training institutions to do as well. So thank you for sharing that. Yeah, thank you. I want to turn to Michael. Michael, you have an
extraordinary story– a story not just of how you
worked through addiction and came out on the
other side, but a story of how you turned
pain into a passion for helping other people. And I think it’s
really extraordinary. And I would love
for you to– we’ve had the chance to
hear your story when we were down in Atlanta
at the Rx Summit but I would certainly
love for you to share some of your experiences
and the journey that you went through with
the folks who are here today. Awesome. Well, thank you for
the introduction. It’s an honor to be on the
panel with doctors as well. I’m also an M.D. My
initials– Mike Duggan. [LAUGHTER] i just want to put that
out there– probably longer than a lot of
people in this room. So I’m very excited to be here,
great discussion so far, happy to participate in it as well. My story certainly isn’t
unique, especially for a lot of the stories we hear today. I grew up in a typical
Irish Catholic family. There was a lot of alcoholism,
a lot of addiction. I grew up playing
sports for a long time. That was my outlet. That’s where I found myself. And I just want to
make something clear. What I share is my experience
and my experience only. And there’s a lot
of path to recovery. I’m a person in
long term recovery. And what that means to me is
I haven’t had a drink or drugs since April 14th, 2009. So I’m very grateful
to recently celebrate seven years in recovery. [APPLAUSE] Thank you. It’s weird looking
up at everybody. I feel like everybody’s
looking down on me right now. Shame on all of you. But in terms of the
process I went through, I just want to make
something clear– that the experimentation
of alcohol and marijuana certainly played
a big part of that and how old I was
when I experimented with both of those drugs, and
the increased likelihood of me developing a substance
use disorder, especially with the introduction
of prescription pain medication when I broke my
wrists from a hockey injury senior year playing hockey. And at that time, I
remember the experience. The first solution to the
pain was prescription opioids. And there was no lesser
alternative given. There was no family
history that was drawn. There was no questions
asked or other alternatives that were discussed. It was also during the time
that OxyContin had first started coming around
in the early 2000s. And I think, at that time,
based on mismarketing practices, it was prescribed
for moderate pain. And when I had
that introduction, it certainly paved the way in
a lot of ways for my decision making afterwards, without
even realizing the control it had over my thinking. And shortly after that
first interaction, I had surgery on my wrists
to repair nerve damage. And the solution to the
pain after the surgery was more prescription
pain medication. And then after that, I also
had my wisdom teeth pulled. And the prescription
for the pain was prescription
pain medication. At that age, it was easier
for people my age that I knew and I grew up with to
access pain medication, either legally or
illegally, than it was to get somebody
to buy them alcohol as an underage individual. And the process for
me had many detours, let’s say, many different
paths that I had taken. I personally have
been on Suboxone. I’ve personally been
on the Vivitrol. I’ve personally
been on methadone. So I certainly tried
different attempts at getting myself
clean and sober. One thing I will mention
is my first experience in a detox program– I
remember them asking me the question, what are your
plans when you get out of here? My planning got me in there. So I just want to
make that clear. The last thing I think
that anybody really should have been asking
me at the time were what my plans were, because
a lot of the information that I was getting
was coming from people that I was using drugs
with versus people who were health care professionals
that were properly educating me on options and resources
that were available to me. And I would tell them
or direct them as far as what direction I was
going to choose to go down. And you know that, obviously
created a lot of pain in a lot of situations that
I wish I never went into. But at the end of the
day, there was a light at the end of the tunnel. Fortunately, I’m here to share
a story of recovery, of hope, having the opportunity to
receive proper long term treatment. And I think the biggest
problem, and the reason why I founded Wicker
Sober was if you look at addiction as a
disease of unmanageability and if you look at addiction
as a disease of isolation, those two things– if
you look at success that 12-step programs
have, for example, part of the 12-step
program is admitting that your life is unmanageable. And I think society as a whole
had unrealistic expectations, expecting me to manage my
own care and get myself well. And I think we were falling
short on the lack of support services in between
the coordination amongst treatment,
which was important. So we started a hotline in
order to work with individuals in the system, in the process of
navigating them and connecting them to resources. I remember being in a
program and being discharged with a phone number list,
saying, here you go, these are some options for you. And a lot of times, I never
made those phone calls. Or when I did, I
would quickly find out that there was limited
bed availability, which would cause me now to either
give up in the process and use because I wanted
to avoid withdrawal, or wait or delay it until,
unfortunately, maybe something happened, a consequence
happened that maybe stopped me in my tracks. And another reason why
we started Wicked Sober was for the families. My mother is a very
intelligent woman. She’s a nurse at Mass
General Hospital. But when it came
to addiction, she was getting a lot of
the advice from me. There’s a lot of stigma. There’s a lot of
guilt. And there’s a lot of shame
within the family. And places she
would call, nobody would give her any
information, saying they need to speak
to me directly, which was unrealistic
at the time. So we do a lot of
work with families, put together treatment plans,
coach them on education, coach them on support
groups that they can attend, like Learn to Cope, which you
recently addressed as well, and were to obtain
nasal naloxone, Narcan, and provide
intervention services and help them talk to
their loved ones as well. Well, thank you, Mike, for not
just your story, but for all you’re doing to help
other people as well. Thank you. Appreciate that. You mentioned naloxone and
the nasal Narcan as well. And as it turns out, I
have some demos right here for those of you who
may not have seen this. Now, the reason I bring this is
because I think many of us who see patients have had the
experience of having seen a patient in a clinic
or in the hospital and asking the patient, so
what medications are you on, and they can’t tell
you the medicines, but they pull out
a handful of pills that are blue and red
and pink and white. And they say, well, you
probably know what these are. These are my medications. And of course, in the back of
your head, you’re thinking, I have no idea what
these are because I don’t know what they look like. Well, it turns out that part
of what we’re trying to do is ensure that more people
have access to naloxone. So I wanted to make sure
people knew what these actually look like. So what I have here are an
injectable dispenser for Narcan and also a nasal
dispenser for Narcan. And this is relatively
new, the nasal formulation. But these are
relatively easy to use. And it turns out that it
actually gives you instructions that you can hear. And how many of you have
actually seen this before and used it? So just a few people. So what I’m going to do is I’m
actually going to take it out, and the I’m going to
hold it up to the mic so you’ll hear what
it actually says. [BEEPING] This trainer contains
no needle or drug. Precautionary. [BEEPING] So then what I’m going to do
is I’m going to take this off. –to inject, place black
end against outer thigh, then press firmly and hold
in place for five seconds. Do you mind if I demo on you? There’s no need, but– To inject, place end– Ow. –three, two, one. [BEEPING] Injection complete. And that’s literally it. This trainer may be reused
for training purposes. Let’s make sure this
quiets down a little bit. Hold on. –and white outer case. This is always the hardest
part of the demo, is getting it to quiet down again. There we go. This is the nasal application. And, here this is
actually fairly simple. What you do is you hold
it with two fingers, put your thumb behind, which
is where the release is. And then you insert this
into one nostril, either one, doesn’t matter. And then you just
simply push on the back. And that dispenses
the medication. You just need to give one dose. This is a one dose cartridge. And then you wait
two to three minutes to see if there’s a response. And if there isn’t, then
you can give another dose, both of the intranasal
one, and also you can give a second dose of
the injectable as well. So it’s that simple. Now, different states have
different rules around Narcan. Some states, it’s actually
quite hard to find. Others have made it much
more easily applicable. In Baltimore, for example, they
have a standing prescription where anyone can walk in
and actually get naloxone, whether you’re using
opioids or not, because we know that many
times, family members play an important role
in administering this to their loved ones. So this is what Narcan is about. But I also just want to touch
on one thing that Mike said, which is about the
treatment, the phone numbers that you said you were
given several times when you were in the hospital. I’m willing to bet that
every clinician in the room has had the experience
of sending a patient out with a phone number
to call for help and knowing somewhere
in the back your head that it was very unlikely
that they would actually be able to use that. And that feels
really, really bad, because you feel
like, gosh, I really know there’s more
this person needs, and I can’t actually provide it. So I’m making both of us feel
better by just giving the phone number. And what that points
to is the fact that if we really want to
provide the help that people need, if we really
want to tackle the problem of
addiction, we have to ensure that the full
set of wrap around services are available. And whenever we talk
about more services, it sounds like more money. And says, well, where are we
going to the money for it? Well, what I would say
is that we can’t actually afford not to do that, because
we are paying far more in terms of emergency room visits, in
terms of lost productivity, in terms of human suffering than
we could be if we only invested more in the treatment side. And that’s one of the reasons
why President Obama actually made it a point in his budget
request for the next year to request about $1.1
billion in new funds to fight the opioid epidemic. And a significant
portion of that is going to expanding treatment. If it’s actually
funded by Congress, about up to $20
million of those funds would actually come to
Massachusetts, as well. But this is why those
funds are so important. It’s because it’s about
providing the kind of follow up services, wrap around services,
that folks like Michael and so many others need when
they’re dealing with addiction. I want to now just
turn to our audience. We have time for
a few questions. So I wanted to see if anyone
would like to ask anything. Sure. Right over here. Hi. Good afternoon. Thank you so much for
coming to speak at Harvard. My name’s Danielle Beck, and I’m
a fourth year medical student here. And I recently completed the
eight hour Suboxone training here as part of a pilot study. And I’m also a member
of the Student Coalition on Addiction in Massachusetts. And we completed
a statewide survey that showed a serious
gap between wanting to be trained in order to treat
patients with substance use disorders and actually having
the skills to treat patients with substance use disorders. Given this gap in
training, would you support Suboxone
training being integrated into the medical student
curricula across all states nationwide? I would. I think it’s important
for all clinicians to know how to treat
substance use disorders. If you think about
it, whether you’re a cardiologist or
a dermatologist or an ophthalmologist,
you’re given basic training in how to adjust blood
pressure medications. And you’re giving that training
because, even if you don’t use it every day, it’s a basic
skill set that we have to have, especially given the
prevalence of hypertension. Substance use
disorders are becoming increasingly prevalent. And what is clear also is that
people living with substance use disorders don’t
always have easy access to the medical system. What that means is that
we should be moving toward, essentially, a
no wrong door policy, whereby any interaction
with the health care system enables someone
living with addiction to be able to encounter
someone who can provide them with treatment. And so that’s why,
yes, I would be supportive of
expanding our treatment and making this and
thinking about substance use treatment as part of
the basic tool kit that every clinician
should have. Thank you. Thank you all so much
for the wonderful work that you have been doing
and for addressing us today. This has been a
great discussion. My name’s Scott [INAUDIBLE],
and I work as an adolescent medicine physician and addiction
medicine physician here at Boston Children’s. And Mike, your story
really resonated with me, because I see a lot of patients
in exactly the position that you found yourself in. I can think of a
16-year-old patient who I started on buprenorphine
a couple of weeks ago. I remember sitting there,
starting him on the medication because he’d been struggling
with methadone and other pills that he had been
buying off the street. And as I was doing
the induction, he was sitting there
reading a Harry Potter book. And I remember thinking,
this is such a juxtaposition of something that we think of
as a typically adult disorder combined with somebody
reading a book that’s made for children in my exam room. And so my question
for the whole panel is what thoughts do you
have and what efforts are we making at the local,
state, and national level to address prevention and
treatment for young people, since we know that
the life course trajectory of these
things starts quite early? Did you want to [INAUDIBLE]? Were you directing the
question to Michael? Yeah. Well, I think a lot
of us could certainly touch base in different
aspects to that question. One thing I just want
to mention in terms of medication-assisted
treatment is medication isn’t the treatment. It’s just a treatment
aspect to that as well. It’s very important. When I went to an
out patient program, I would go to a Suboxone doctor. And then I would go
to a Vivitrol doctor or I’d go to somebody who
prescribed me methadone. I think we have to provide
all options to find out what’s going to be best
for the individual, not necessarily what’s
going to be best for the provider, prescriber. And in terms of
where stigma can be a huge problem is if
you’re referring out to an abstinence-based program
as part of your treatment when you’re on medication
like buprenorphine, that may not be something that
an individual feels necessarily comfortable in versus being
in a group with other people that are on the
similar type medication that they are as well
receiving treatment. And I think that happens a lot. In terms of work,
as of right now, there’s a ton of advocacy work
and grassroot organizations that are going into a
lot of the high schools, a lot of the middle schools,
and having the conversation. So that’s obviously
very important. There’s still that concern
that a lot of parents have that they don’t want
to have the conversation with their children. They think it’s too early to
have that conversation as well. So we still have to
overcome those obstacles when we go into the schools,
when we speak to the students. A big problem for me, in terms
of the possible directions that I take, that
I had taken, was addiction is a chronic illness. And it needs to be
treated as such. And there was limited
case management services that were done. I know you had mentioned how
much we’re costing by not doing anything differently. And a lot of times,
it’s detox only, which detox is a quick
fix solution that we’re providing the
highest level of care and providing the most
expensive services, and we’re discharging an
individual with no follow up care. So we’re really missing the wrap
around services and the case management services to work with
people on a long term basis, providing them a
continuum of care. And I think that’s where
we still fall very short. But we’re making extreme strides
in the right direction, which is good. Let’s see if we can fit in
maybe a couple last questions. Go ahead. Thank you so much. It’s truly a
privilege to be here, a part of your leadership
around these issues, Surgeon General
Murthy and our panel. My name is Patrick [INAUDIBLE]. I’m a primary care doctor at
Lynn Community Health Center. I’ve also trained at the Mass
General Hospital and practice at Mass General. And I wanted to make a point
about and ask a question about the integration
of services. So we all know that pain
is multi-disciplinary. And there are many ways to
treat it other than opiates. And I can think about the
difference in my practice at Chelsea Health Center and
Lynn Community Health Center, where we have the
privilege of being set up with a really rich set of
neighborhood health services, so that when I meet a patient
with addiction or with, perhaps, an appropriate
opiate– benzodiazepine use, for example– I can tap
colleagues for warm handoffs to assess whether
they’re catastrophizing around the pain, whether there
are behavioral components around that, whether we’re
appropriately addressing various traumas in a
trauma-informed way– I feel able to provide the care
I need for my patients without having to own that
all in a 15 minute visit. We also have team structures
so that patients are reviewed on a monthly basis
who are high risk and who have the support
of a team’s recommendations as I go back to a
patient to explain why we may need to move them off
those [INAUDIBLE] prescribing or reduce their level of dose. And so how do we think about
the structured integration that support the ability
of us to provide the care at the point of care? So Pat, I will address
that in a little bit. Nice to see you. So I think part of
the reason of coming to you here as this group
is the answers are here. So we know that team-based
care is good for diabetes. We know that engaging
multiple disciplines across different sectors,
even outside of medicine, is the way to take
care of people with cardiac best
or cancer survivors. The same holds true for
substance use disorder. You know models
of care, as I do, where the behavioral health
is integrated directly into the primary care. And those are the best models
and the most successful. So for you all, as leaders
in the field of medicine, I would ask you to
think about ways to get these models and
these best practices and enhance them
throughout the system, because I think this is a real
opportunity for us to finally get issues of behavioral
health illness incorporated as they should be in primary
care in a holistic way. Go ahead. Thank you. Scott Sigman, I’m a practicing
orthopedic surgeon here in Massachusetts, also a member
of Governor Baker’s new Chronic Pain Management Commission. So elective surgery,
in Mike’s story, is a very common one, has
become an inadvertent gateway to the substance use problem. And as many as one
out of 15 people that are exposed to opioids in
the setting of elective surgery will go on to substance use. So we’re doing a
really great job here trying to re-educate
our physicians. We now want to also try to
educate our patients to have them empowered to recognize that
there are opioid alternatives that are out there. For example, I use
liposomal bupivicaine with excellent success and
really dramatically reducing the need for
post-operative narcotics. One of the problems
that we’re seeing here in Massachusetts, as well
as across the country, is that the cost of the
use of the medication is considered too much. We have silo pharmacy budgets. We have hospital
administrators who are saying, it’s too much money
on the front side. And I guess the question
I have is for a strategy as to try and balance the amount
of money used for prevention to, say, down the road,
can we save lives, and can we also reduce the
overall cost to society? So are there
strategies that we can talk about where we can balance
that out with prevention? I certainly appreciate
that comment. And I think what you
shared is actually a concern I hear all
around the country, which is that the
alternative sometimes costs more than the opioids,
whether that’s IV Tylenol or whether it’s going
to PT three times a week and having to dish out a
co-pay each time you go, which is more time
and more money. So there’s certainly
an issue here. And I think part of
what we are working on, and I think what we need
to collectively work on, is in having more conversations
with payers about how we shift and change what we
pay for, recognizing that investing more in
lowering the cost of some of these alternatives upfront
can save us a lot more cost down the line. But I think this also points
to the importance, again, of integration, because the
more we have integration with different elements of our
health care delivery system, I think the easier it is for
us to understand the costs and benefits of different
decisions we make. Many of us have operated in a
fairly siloed universe when it comes to practicing medicine. And we can see, even
on a small scale, that when you have
consult services that don’t talk to each other,
that can cause tremendous pain for everyone. That can cause increases
in length of stay. That can cause increases
in complications. So I think the integrated
systems, some of which we saw earlier today at Boston
Health Care for the Homeless and also at the Boston
Medical Center these are great examples, I think, of
how we need to bring services together. But they have to
also be combined with conversations with payers. And that’s part of what
we’re trying to drive now. I think that there’s a
recognition that there are many folks who probably
contributed to this problem over time, but now it’s our time
to all come together and chip in and make sure that we
are a part of supporting the solution. I know that our time
has nearly run out. So let me just take
one more question then I’ll take a comment at the end. Go ahead, sir. Thank you for coming. I really want to,
first, start off by saying that I
love your hashtags. So I’ve used #stepitup. And now, #turnthetide is great,
because I’m from New Bedford, and so we’re, in
New Bedford, one of the small cities
in Massachusetts that’s struggling with
the opioid crisis. I’m Dr. Mike Rocha. I’m a cardiologist. I’m actually not from Harvard. I’m a UMass Medical Center grad. And I actually trained at Tufts. But we really are
struggling in our community. And one of the things that
we’ve tried to look at is how do physicians in
a community setting– because we’re here in
an academic setting– and how do we come together in
communities where we need to be on the ground to get that done? And I’m going to
share with you what we’re doing in New Bedford. What we’ve done over
the last several months is we’ve put a
coalition of doctors together from all
subspecialties– cardiology, anesthesiology, emergency
room physicians– and we’ve decided to embrace
the Turn the Tide in what we were trying to do. And exactly the
things that you’re talking about at the
community level– we’re talking about advocacy. So what has to change
in our community, how we can connect with people
outside of our community, public health education, which
we’ve already showed the movie “If Only” and had James Wahlberg
come down to our community to get that conversation
going with the kids, and also to improve physician
pain medication practices. And last night, we
actually had 85 doctors at a restaurant in
New Bedford that had a continuing medical
education meeting last night with
Dr. David Kassovitz from Boston Children’s Hospital. And we met with our mayor. So what we recognize is that
we have tremendous power when we work together. And I think that’s
one of the things, as physicians, that
sometimes we forget, is that we work in our own
offices, our own emergency rooms, our own operating rooms,
and that when we really come back to what we’re supposed to
be doing is to help and serve our patients, if we
just show up and care with hope and compassion, we
can make a big difference. And what I’m going
to ask is this how do we leverage our
practitioners in the community to come together in a way that
we aren’t reaching right now? Now, we can talk about it
at the public health level. But how do we interact
with public health and the clinicians better? That is a really good question. I have a lot of
thoughts on that. But let me do one thing,
if you don’t mind. I’m going to hold your
question for a moment. I want to get a comment
here, and then I’m going to come back and
answer your question, OK? And we’ll wrap up the session. I wanted just give
a moment to Shoma and to Blaine, who are
two of our partners who are here, because I
want them to share something that they’re helping
work with us on. Shoma is from the Institute
for Healthcare Improvement, and also Blaine is from PHFE. And both of them have been
incredibly important partners for us in building this
Turn the Tide campaign. And in addition to sending
the letter and the pocket card out that I mentioned,
we are also creating a website where
we can have clinicians go to understand what
other clinicians are doing, to hear some of their stories
about how they changed their practice,
where they can also hear the stories of patients
who encountered clinicians who helped them, where they
can print out materials that they can share with
patients, a simple way to educate people who are
coming through their door. So I want to give Shoma
and Blaine a chance to share a little
bit about that. Thank you so much. It’s such a privilege to be
partnering with you in this. And in many ways,
Mike, your question is at the heart of
what we’re doing, which is to say, how can we
really think about the fact that this needs, as the
Surgeon General said, a community-wide approach? And if it takes a
community-wide approach, we need ways to bring
community together across health care,
public health, patients, community members. And so at 100
Million Lives, what we’ve been doing
is building some of the tools, the
resources to make that possible for people,
and also for people as, for instance, the
State Without Stigma– what a fantastic thing to do, or
what Wicked Sober is doing– how can we make these bright
spots visible to everybody across the country so
that New Bedford might be inspired by what
Wicked Sober is doing and what Boston is doing? And Boston might be inspired
by what New Bedford is doing, and what a community in Alabama
might find that they develop can actually help to accelerate
our collective work together. 100 Million Healthier
Lives is all about creating unprecedented
collaborations that recognize that people with
lived experience, community members, and community leaders
across sectors, all the way to the federal
level, all need to be part of creating the
solutions together. And it’s just an absolute
honor to be helping to partner in this way to
address what, as a primary care physician, I have
found in my patients to be one of the most
challenging issues of our time. And I just thank the
Surgeon General’s office for taking this on and for
doing it so intentionally, and in a way that is so
humane in the way in which it calls people to action. Thank you so much. Good afternoon, everybody. It’s a great honor to
be here this afternoon to address this
devastating health crisis that you’ve heard this afternoon
affects all of our communities, from South Boston to
Cambridge to Paisley Park. And I really want to
applaud the Surgeon General for taking a bold and
innovative approach in moving us from awareness to action. I’d also like to acknowledge
three of our PHFE board members who are here with us today. As an infectious disease
physician by training, I come from a world of
HIV, where no one really believed, in 1991, that
25 years later– that is to say, in 2016– the
end of the AIDS epidemic in cities like Boston
and New York would be a realistic discussion
that we might be having. However, those discussions
are taking place today, because as you’ve heard,
when we come together in collaborative
and meaningful ways, we can tackle even the most
intractable public health challenges. And that is our call
today to action, as you’ve heard from
the Surgeon General and this wonderful panel. As a national
nonprofit agency that provides program and support
services to optimize population health, PHFE, or Public
Health Foundation Enterprises, was thrilled when the
Surgeon General reached out and approached us to
take the lead with IHI in building a different
and dynamic partnership and an innovative
digital platform to reach prescribers
in addressing the opioid crisis in America. This collaboration
and our support in bringing together
the talent and resources to build this new
platform, creating a digital home for this work
is a natural fit for us. PHFE’s service model
is built on advancing evidence-based programming
through partnerships with academic researchers,
innovative public-private consortia, and
government agencies so that we can bring lasting
structural change that improves the health of communities. And we do this in
a variety of ways. We bring evidence-based
pilots to scale, partnering on
innovative social media and marketing, as
we have done here, building creative
fellowship opportunities, providing fiscal
sponsorship or grant development and
administrative support for large research and
population health initiatives. PHFE currently partners
with researchers at UCSF and the San Francisco
Department of Health to better understand key
aspects of this crisis, including evaluating trends
in local opioid overdose death rates and analyzing
this impact of change in prescriber practices and
illicit opioid initiation and overdose. Additionally, PHFE supports
the LA Community Health Project, which provides
overdose prevention and naloxone training throughout
Southern California, links those affected by drug
use to primary health care, offers hepatitis C testing,
and provides other kinds of outreach and support. Most recently, we have
partnered with IHI’s 100 Million Healthy
Lives to exchange promising evidence-based
strategies and outcomes from our work with
other organizations that are seeking to make meaningful
and impactful change around the world. These partnerships and
others are more completely described on our
website, And I invite you to
visit our website and follow us on our
social media channels. Finally, it’s
clear to me– and I hope it will be to you today–
that in reaching out to two large nonprofit organizations
whose missions center on collaboration with
partners across all sectors, that the Surgeon General is
sending an unequivocal message that business as usual
for us as physicians will not be enough to
reverse the worsening opioid crisis in America. We now need to
partner in new ways, as you’ve heard today, across
silos of institutions, research areas, research sectors,
harnessing cutting edge technologies and communication
platforms, educating ourselves and others in
evidence-based strategies that can be brought to scale
so that we can apply our best skills and talents toward
turning the tide on this most unfortunate epidemic, as we have
done with other public health epidemics in our recent past. So in collaboration with the
Office of the Surgeon General, PHFE stands ready to embark on
this journey with all of you. And we thank the Surgeon
General and this wonderful panel for your help today. Thank you. [APPLAUSE] I want to thank everyone
for coming today and for participating
in this conversation. I want to thank in particular
our wonderful panelists, Dr. Burrell, Dr. Wakeman,
and Michael Duggan for sharing some of their
experiences and perspectives with us. And I just also want to say
this in closing, and partly in response to your
question, Dr. Rocha. It was a perfect question
to actually end on, because you brought
up the issue of power. And one thing that I’ve often
thought of over the years is that clinicians are looked
at by people on the outside as people who have tremendous
power and influence. But many clinicians
themselves feel disempowered. They feel like they
are being asked to do more and more
with less and less. They feel that they
are seeing problems that are bigger than the
skill set that they have to apply to those problems. And as time goes on,
people feel like they’re operating in large institutions
that often don’t care that much about them, that they
can’t actually influence. And there’s a strange
dichotomy between the power that people think we have and
the we sometimes feel we have. But the truth, I think, is
that we do have more power than we believe. I had a member of
Congress tell me once that he got constituent
calls all the time, that he would say,
if, in one day, one call came in
from a doctor, that was listed as a notable event. He said, if 10 calls came from
doctors on a given day, that was a full blown crisis. And it just went to show
how infrequently members of Congress actually
hear from clinicians. But I will tell you
from my experiences, even long before I was Surgeon
General, that I have seen time and time again when clinicians
take an issue up of importance, whether it’s substance use
disorders, whether it’s mental health, whether it’s
violence, that communities listen, that they care and
they need and appreciate that leadership, because
our voices are more powerful than we often realize. And we have the ability
to affect more change than we sometimes recognize. So I want us to
think about that, because to overcome
this epidemic, we’re actually going to have
to do that kind of organizing. We’re going to have to come
together in communities and not only help each other
change our clinical practice, but we’ll have to demand what
it is that we and our patients need. If that’s better
reimbursements for alternatives to opioid medications,
then that may be it. If it’s more
integrated service so that we don’t have to send a
patient out with just a phone number and just
hope for the best, then that integration is
what we have to fight for. If it’s more funding
for treatment programs so that people can actually get
medication-assisted treatment, then that is what we
have to fight for. But I want you to know now,
being on a different side of the fence and sitting
inside government, that I can tell you firsthand
that when clinicians speak up, people do listen, even if
it doesn’t feel like it. And especially on
a local level, you do have the ability to
change how we operate and how we do business. But it takes us stepping out
of our comfort zone, often. It takes us stepping
out of the role that we were trained to play. And I would love, in the
future, to see medical students and residents trained not
only in how to provide care to patients, but
in how to advocate for them, especially when they
can’t speak up for themselves. That’s a skill that’s
essential to all of us. When we look back
in 20 years, I want us to be able to
look at this moment and say that this was an
inflection point in time. This is a time where
the country woke up to the magnitude of
the opioid crisis, where we realized just how
many lives were being destroyed by it, but also a
moment where we decided to do something about it. And I want this to be a
moment where we, as clinicians in particular, can look back and
say that this is the time where we stepped up to take that
role upon us that society so often wants us to step
into, a role as a leader, a role as an advocate, a role
where we can help change what’s happening in our communities
and ultimately create a foundation for better health. So I want to thank all
of you for your interest in being part of
that movement that we are building to turn the
tide on the opioid epidemic. I want to thank you also
for the work that all of you do each and every day to
better health, whether it’s for individual patients
or whether it’s for the entire state
of Massachusetts. And certainly, we are looking
forward to having all of you join the movement. You should get the
letter in July. And even if you don’t
get it in the mail, we’ll make sure
that it’s sent out through as many
organizations as possible so that you can sign up, so
that you can take that pledge, and so that you
can join physicians from all 50 states who want
to be a part of the solution. Thanks so much. Thank you, Dean Flier. It was great to be
with all of you today. I appreciate it. [APPLAUSE]


  • Reply MOUSAMI KEERTHI June 26, 2016 at 5:45 pm

    He is indeed right…addiction is not a character flaw or moral failing..

  • Reply Not Provided August 30, 2019 at 2:22 am

    You could prevent a great deal of opioid addictions by legalizing cannabis and letting people use It as a alternative to the prescription opioids that people get

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